ICD-10-CM Coding Guidelines, Exams of Nursing

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A 55-year-old female with right hydronephrosis presents for a cystourethroscopy with a retrograde pyelogram. What ICD- 10 - CM coding is reported? - Correct Ans: ✔✔N13. Rationale: The indication for the surgery is hydronephrosis. In the ICD- 10 - CM Alphabetic Index, look for the main term Hydronephrosis. There is no indication of causal organism, or that it is a congenital condition. The default code is N13.30. A review of this code in the Tabular List confirms this is the correct diagnosis. A woman is readmitted one week after delivery with a diagnosis of delayed hemorrhage due to retained placental fragments. What ICD- 10 - CM coding is reported? - Correct Ans: ✔✔O72. Rationale: Look in the ICD- 10 - CM Alphabetic Index for Retention/placenta/portions or fragments (with hemorrhage) O72.2. Verification in Tabular List confirms correct code choice. A male newborn, delivered vaginally in the hospital, is born with jaundice. What ICD- 10 - CM coding is reported for the newborn's record? - Correct Ans: ✔✔Z38.00, P59.

Rationale: The question is asking for the codes for the newborn's record. According to the ICD- 10 - CM guidelines I.C.16.a.1 codes from the obstetric chapter (Chapter 15) are never permitted on the newborn record, do not report codes O80 and Z37.0. ICD- 10 - CM guideline I.C.16.a.2 indicates, the first listed diagnosis code, Z38.00, is used to report the birth episode, followed by additional codes for perinatal conditions. Look in the ICD- 10 - CM Alphabetic Index for Newborn/born in hospital. You are referred to Z38.00. In the Alphabetic Index, look for Newborn/jaundice and you are referred to P59.8. Look in the Alphabetic Index for Jaundice/newborn and you are referred to P59.9. In the Tabular List, P59.9 is unspecified which is correct for this case. Verify all codes in the Tabular List. The hospital documentation states "normal vaginal delivery, live birth, female, with Down Syndrome." What ICD- 10 - CM coding is reported for the infant's record? - Correct Ans: ✔✔Z38.00, Q90. Rationale: According to ICD- 10 - CM guideline I.C.17 for birth admission, the appropriate code from category Z38- Liveborn infants, according to the type of birth should be sequenced as the principal diagnosis, followed by any congenital anomaly codes Q00-Q99. To find the type of birth, look in the ICD- 10 - CM Alphabetic Index for Newborn/born in hospital Z38.00. Down Syndrome is reported secondarily and is found in the ICD- 10 - CM Alphabetic Index by looking for the main term Down Syndrome, Q90.9. Although category Q90 has a use additional note to also report associated physician condition and degree of intellectual disabilities, this is a newborn and this information is not known so it is not reported.

When should a code for signs and symptoms be reported? Refer to ICD- 10 - CM guidelines I.C.18.a and I.C.18.b. - Correct Ans: ✔✔When it is not integral to the definitive diagnosis. Rationale: Signs and symptoms are reported when a definitive diagnosis has not been established. If the sign or symptom is not integral to the definitive diagnosis, the sign(s) and symptom(s) should be reported. A patient was sent home with a PICC line for Vancomycin treatment at home. He returns to his physician with an infection due to the PICC Line. The infection is determined to be MRSA. What ICD- 10 - CM coding is reported, in the correct sequence? - Correct Ans: ✔✔T80.218A, A49. Rationale: When complications are reported, a code for the complication is reported first. If the cause of the complication is known, it is reported as the additional code(s). Look in the ICD- 10 - CM Alphabetic Index for Infection/due to or resulting from/central venous catheter/specified NEC T80.218-. Verification in the Tabular List indicates this code needs a 7th character. 7th character extension A is reported for the initial encounter. T80.218A is correct because we do know that this is an MRSA infection, however, we do not know whether it is a local infection or bloodstream infection. Next look for MRSA (Methicillin resistant Staphylococcus aureus)/infection A49.02. Verify code in the Tabular List.

The patient was hit in the nose by the ball playing basketball on the varsity team last evening at the gym and woke up with severe epistaxis. The family physician controlled the nasal hemorrhage with cauterization and afterwards packed the nose with nasal packs. What ICD- 10 - CM coding is reported? - Correct Ans: ✔✔R04.0, W21.05XA, Y92.39, Y93.67, Y99. Rationale: The epistaxis is caused from an injury; it is not hereditary. This is found by looking in the ICD- 10 - CM Alphabetic Index for Epistaxis (multiple) and using the default code R04.0. Four external cause codes are required in this case. The first code indicates how the injury occurred (hit with a ball). Look in the External Cause of Injuries Index for Struck (accidentally) by/ball (hit) (thrown)/basketball W21.05-. Add a placeholder X for the 6th character and an A for the 7th character to indicate initial encounter, W21.05XA. The next code reports where the accident occurred. Look for Place of occurrence/Gymnasium, Y92.39. Next, code the activity he was involved in at the time. Look for Activity/basketball Y93.67. The last external cause code is a status code. Look for Status of external cause/student activity, Y99.8. The patient's dense breast tissue made the screening mammogram unreadable, and she is here today for a breast ultrasound. Her mother and sister both have history of breast cancer. What ICD- 10 - CM coding is reported? - Correct Ans: ✔✔Z12.39, R92.2, Z80. Rationale: Code the special screening as a reason for the encounter, along with a code to report the patient's breast density, which provides medical necessity for a more extensive test. Dense breast tissue occurs

in many premenopausal women, and can interfere with reading a mammogram and may mask abnormalities in the image. Look in the ICD- 10 - CM Alphabetic Index for Screening/neoplasm (malignant) (of)/breast Z12.39. For the breast density, look in the Alphabetic Index for Dense/breasts R92.2. This code provides medical necessity of an ultrasound. To report the family history of breast cancer, look in the Alphabetic Index for History/family (of)/malignant neoplasm (of)/breast Z80.3, which may provide medical necessity information for the screening exam in a young patient. Verify all codes in the Tabular List. CASE 1 Office note: RE: Injection, strapping of foot and ankle. Chief complaint: heel pain(Patient complaint.), 6 months' duration. No inflammation, no heat. Diagnosis: Heel spur.(Definitive diagnosis. The heel pain is a symptom of a heel spur.) Treatment: Weight reduction, injection of Celestone, Xylocaine plain, pulses good, DTR, vibration and temp normal.

Orthotics suggested; better shoes suggested. Lawyer by trade. Criminal trial attorney. Referred by his partner. Discussed diet, orthotic shoes. Return if need be in 61 days. What diagnosis code(s) are reported? - Correct Ans: ✔✔M77. CASE 2 Reason for consult: Acute renal failure (Indication for the visit.) HPI: The patient was followed in the past by my associate for CKD, with baseline creatinine of 1.8 two weeks ago. Found to have severe ARF this morning associated with acidosis and moderate hyperkalemia after presenting to the ER with complaint of dehydration. (These conditions werediagnosed by another physician in the emergency room.) The patient is admitted under observation status to the hospitalist service and the renal team is called for a consult. ROS: Cardiovascular: Negative for CP/PND. GI: Negative for nausea, positive for diarrhea. GU: Negative for obstructive symptoms or documented exposure to nephrotoxins. All other systems reviewed and are negative. PFSH: Negative family history of hereditary renal disease and negative history of tobacco or ETOH abuse. EXAM: Constitutional: 99/52, 18, 102. NAD. Conversant. Eyes: anicteric sclera, - Correct Ans: ✔✔N17.9, E86.0, N18.30, I95. CASE 3 PROGRESS NOTE

Chief complaint: Multiple ulcers. Subjective: The patient returns, accompanied by her caregiver who states that she believes the ulcers have gotten "about as good as they are going to." The edema of the leg seems to be controlled much better. Objective: Exam reveals marked improvement of the edema (The edema is improving.) of both lower legs, the right is better than the left. All of the ulcers are now extremely superficial and seem to almost be partial thickness skin.(The ulcers are healing.) There is no cellulitis. The only uncomfortable area seems to be on the sole of the left foot where there are considerable bony abnormality and/or tophaceous deposits which have distorted the bottom of her foot dramatically. To relieve the left foot pain,(Location of the foot pain. Patient had foot pain likely due to tophaceous deposits which are an indication of gout. This is not a definitive diagnosis docu - Correct Ans: ✔✔L97.521, L97.511, R60.0, M79. CASE 4 Subjective: The patient presents today after having a cabinet fall on her.(This describes how the injury occurred.) She states the people who put in the cabinet missed the stud by about two inches. The patient complains of cephalgia,(Patient complaint.) primarily occipital, extending up into the bilateral occipital and parietal regions. The patient denies any vision changes, any taste changes or any smell changes. The patient has marked amount of tenderness across the superior trapezius.(Patient complaint.) Objective: Her weight is 188 which is up 5 pounds from last time, blood pressure 144/82, pulse rate 70, respirations are 18. She has full

strength in her upper extremities. DTRs in the biceps and triceps are adequate. Grip strength is adequate. Heart is a regular rate. Lungs are clear. Assessment: 1. Cephalgia

2. Thoracic somatic dysfunction (Select codes for definitive diagnosis.) Plan: The plan at this ti - Correct Ans: ✔✔R51.9, M99.02, W20.8XXA CASE 5 CHIEF COMPLAINT: Right shoulder injury.(Patient's complaint.) MODE OF ARRIVAL: Private vehicle. HISTORY OF PRESENT ILLNESS: The patient is a 59-year-old male who states that just prior to arrival he was going into a supermarket (Where accident occurred) when the revolving door suddenly slammed on him(How accident happened). It caught him across the right side of his chest anteriorly and posteriorly.(Location of the chest injury.) He was unable to liberate himself from the door, and an employee had to help him out. He denies any current shortness of breath, although did say he had the wind knocked out of him. He complains of pain in the anterior and posterior chest wall, posteriorly medial to the scapula. He denies any numbness, tingling or weakness in his right arm; however, he does state that it seems to be painful and difficult for him to either lift or even drop his arm. He again denies any numbness, tingli - Correct Ans: ✔✔S20.211A, S20.221A, S49.91XA, W23.0XXA, Y92. CASE 6

PREOPERATIVE DIAGNOSIS: Congenital hydrocephalus. POSTOPERATIVE DIAGNOSIS: Congenital hydrocephalus. CLINICAL HISTORY: The patient is a 2-month-old boy who was born and was IUGR. He did well for the first several weeks; however, he then developed a large head. Mom noticed full fontanelle arid in the last week or so, and they have noticed the eyes have decreased mobility. He tends to stare straight and has some trouble looking up and even to the sides bilaterally, so she reported it to her pediatrician. Pediatrician ordered a CT scan and referred the patient. I saw the patient yesterday in clinic. We ordered an MRI; MRI was done this morning. Initial read shows the congenital hydrocephalus; however, it is not a Dandy- Walker. We had a discussion with the family about risks, benefits, potential complications and also different procedures. We talked about a third ventriculostomy however, given the patient's age an - Correct Ans: ✔✔Q03. CASE 7 HPI: 20-year-old female, estimated gestational age 25.3 weeks, who presents with red staining after wiping with toilet paper this afternoon. No abdominal pain. Contractions: Negative. Fetal Movement: Present. ROS: Constitutional: Negative. Headache: Negative. Urinary: Negative. Nausea: Negative. Vomiting: Negative.

Past Medical/Family/Social History: Medical History: Negative. Surgical History: Negative. Social History: Alcohol: Denies. Tobacco: Denies. Drugs: Denies. EXAM: General Appearance: No acute distress. Abdominal: Soft. Non-tender. Vagina: Blood clots size: 1.5 cm and amount 2. Discharge:Pink. No hyphae, BV, or TRICH, and CX not irritated. Cervix: Deferred. Uterus: Fundal height: 24 cm. MDM: Labs: FFN, UA R+M, C+S, GC/chlamydia, CBC, type and RH, DAU. Labs reviewed and WNL. Ultrasound: Negative for placenta previa. NOTES: Patient continues with contractions mildly, but does not feel it. Patient given - Correct Ans: ✔✔O47.02, Z3A. CASE 8 This 67-year-old Medicare patient is seen for a screening Pap and pelvic examination at our office today. She is an established patient and is complaining of abnormal vaginal discharge on and off for approximately three weeks. She denied any trauma. Patient is not sexually active and her LMP was ten years ago. She denies any chest pain, shortness of breath or urinary problems. Patient had Pap and

pelvic exam one year ago and is requesting a Pap and pelvic exam today. Patient was presented with an ABN which was signed. Past Medical History: Two vaginal deliveries, one in 1965 and another in

1967. Allergies, unknown. Medications include Micardis 80 mg for hypertension. She does not smoke or drink. She is married and lives with her husband. Examination: Vital signs: BP= 125/70. Pulse= 85, respirations= 20. Height= 5' 5". Weight= 135 lbs. Well-developed, well-nourished female in no acute distress. HEENT: Pupils eq - Correct Ans: ✔✔Z01.411, N89. CASE 9 PREOPERATIVE DIAGNOSIS:
1968. 2 cm transverse laceration of right forehead.
1969. 3 cm stellate laceration of right upper eyelid.
1970. 3 cm trap door laceration of right lower eyelid. OPERATIVE DIAGNOSIS: OPERATION PERFORMED: Multiple-layer closure of above lacerations totaling 8 cm. Anesthesia: Local. PREOPERATIVE NOTE: This patient is a 64-year-old white female. She has a very difficult time ambulating, doing so with a walker and intermittently sitting. This evening, unfortunately, she fell from her motorized wheelchair that was moving and struck the right side of her forehead. She was brought to the emergency department where she

was thoroughly evaluated by Dr. Tim and is in the process of getting C- spine films and is accordingly in a cervical spine support. I was called to evaluate and treat these lacerations due to their extensive and complex nature. The lacerations are as described above. Forehead laceration is - Correct Ans: ✔✔S01.111A, S01.81XA, V00.811A CASE 10 PREOPERATIVE DIAGNOSIS: Right forearm radial shaft fracture with possible mild distal radioulnar joint subluxation. POSTOPERATIVE DIAGNOSIS: Right forearm radial shaft comminuted fracture with possible mild distal radioulnar joint subluxation. ANESTHESIA: Axillary block with general anesthesia. OPERATION: Right radius fracture open reduction and internal fixation with closed reduction distal radioulnar joint INDICATIONS: This is a 22-year-old male, who sustained a right forearm fracture injury as indicated above and in the medical records and office notes. DESCRIPTION OF PROCEDURE: The patient was placed under axillary block in the holding area, followed by general in the operating room. Patient identification, correct procedure, and site were confirmed. Antibiotics were provided in an appropriate fashion preoperatively. A dorsal/posterior approach to the fracture was performed with a standard recommended inc - Correct Ans: ✔✔S52.351A

The provider documents CKD stage 5 and ESRD. What ICD- 10 - CM code(s) is/are reported? - Correct Ans: ✔✔N18. Rationale: According to ICD- 10 - CM guideline I.C.14.a.1 when both a stage of CKD and ESRD are documented, you assign only code N18.6. Verify code selection in the Tabular List. Can Z codes be listed as a primary code? - Correct Ans: ✔✔Yes, Z codes can be sequenced as primary and secondary codes. Rationale: ICD- 10 - CM guideline I.C.21.a indicates Z codes may be used as either a first listed (principal diagnosis code in the inpatient setting) or secondary code, depending on the circumstances of the encounter. Z codes are not external cause codes. The external cause codes are listed in chapter 20 in the Tabular List and begin with alpha characters V, W, or Y, and can only be reported as secondary codes. What is the definition of a postpartum complication? - Correct Ans: ✔✔Any complication occurring within the six-week period after delivery. A patient has benign prostatic hyperplasia with urinary retention. What ICD- 10 - CM code(s) is/are reported? - Correct Ans: ✔✔N40.1, R33.

Rationale: In the ICD- 10 - CM Alphabetic Index look for Hyperplasia/prostate/with lower urinary tract symptoms (LUTS), guiding you to code N40.1. In the Tabular List there are instructions below code N40.1 to "Use additional code for associated symptoms, when specified." Code R33.8 is listed for urinary retention. Verify code selection in the Tabular List. A 32 - year-old who is 21 weeks pregnant (antepartum) presents with vaginal bleeding. She is admitted to the observation unit to rule out a spontaneous abortion. What ICD- 10 - CM code(s) is/are reported? - Correct Ans: ✔✔O46.92, Z3A. Rationale: In the ICD- 10 - CM Alphabetic Index look for Hemorrhage, hemorrhagic/antepartum (with), guiding you to code O46.90. Turn to the Tabular List. The 5th character 0 is for an unspecified antepartum hemorrhage, unspecified trimester. Notes at the beginning of chapter 15 indicate that 21 weeks lies in the 2nd trimester. Further review of the codes in this category show that 5th character 2 indicates second trimester, resulting in code O46.92. Code Z33.1 is only reported when the provider documents the medical condition is not related to the pregnancy. The spontaneous abortion code O03.9 is not reported because it is documented as a rule out. Z34.92 is for supervision of a normal pregnancy, which is not the case in this scenario with vaginal bleeding. At the beginning of chapter 15, under the notes, there is a reference to use additional code from category Z3A, Weeks of gestation, to identify the specific week of the pregnancy." Look in the Alphabetic Index for Pregnancy/weeks of gestation/21 weeks guiding you to code Z3A.21. Verify code selection in the Tabular List.

A female patient has osteoarthritis localized in the left hip joint due to senile osteoporosis. What ICD- 10 - CM codes are reported? - Correct Ans: ✔✔M16.7, M81. Rationale: In the ICD- 10 - CM Alphabetic Index, look for Osteoarthritis/secondary/hip, guiding you to code M16.7. Secondary localized osteoarthritis is reported when the osteoarthritis develops as a result of an injury or disease (for example osteoporosis). The osteoporosis is coded as an additional code. In the Alphabetic Index, look for Osteoporosis (female) (male)/senile - see Osteoporosis, age related. Osteoporosis/age-related guides you to M81.0. Verify code selection in the Tabular List. The patient has a left ovarian pregnancy without intrauterine pregnancy. What ICD- 10 - CM codes are reported? - Correct Ans: ✔✔O00.202, Z3A. Rationale: In the ICD- 10 - CM Alphabetic Index, look for Pregnancy/ovarian guiding you to code O00.20. In the Tabular List, the 6 th character 2 is selected to specify the left ovary. ICD- 10 - CM guideline I.C.15.b.1 states to not assign codes from category Z34 with Chapter 15 codes. At the beginning of Chapter 15 there is a note to use an additional code from Category Z3A Weeks of gestation, to identify the weeks of gestation for codes O00-O9A. In this case the weeks of gestation is not documented. In the Alphabetic Index look for

Pregnancy/weeks of gestation/not specified which directs you to Z3A.00. Verify code selection in the Tabular List. Patient is in the facility today for a screening colonoscopy. During the procedure, a polyp is found and removed with a hot biopsy technique. How would this be reported? - Correct Ans: ✔✔Z12.11, K63. Rationale: ICD- 10 - CM guideline I.C.21.c.5 indicates, "A screening code may be a first listed code if the reason for the visit is specifically the screening exam...Should a condition be discovered during the screening then the code for the condition may be assigned as an additional diagnosis." For this question, the screening code is reported first. Look in the ICD- 10 - CM Alphabetic Index for Screening/colonoscopy which directs you to Z12.11. Then, look for Polyp, polypus/colon which directs you to K63.5 as the secondary diagnosis. Verify both code selections in the Tabular List. A patient is admitted to surgery to treat an open fracture to the shaft of the right humerus and a simple closed fracture of the left tibia following a side-by-side ATV accident. What ICD- 10 - CM codes are reported? - Correct Ans: ✔✔S42.301B, S82.202A, V86.99XA Rationale: This is a traumatic fracture since the patient was in an accident. In the ICD- 10 - CM Alphabetic Index look for Fracture, traumatic/humerus/shaft, which refers you to subcategory code S42.30-. In the Tabular List, the code needs seven characters. The 6th character 1 indicates the right humerus. The 7th character B indicates

that this is an initial encounter for an open fracture. The resulting code is S42.301B. The simple fracture is classified as a closed fracture. Look in the Alphabetic Index for Fracture, traumatic/tibia (shaft) which refers you to S82.20-. Verification in the Tabular List shows a 6th character 2 for left tibia and 7th character A for initial encounter for closed fracture. ICD- 10 - CM guideline I.C.19.C.2 states multiple fractures are sequenced in accordance with the severity of the fracture. For the ATV accident, refer to the ICD- 10 - CM External Cause of Injuries Index. Look for Accident/transport/all-terrain vehicle occupant (nontraffic)/specified type NEC directing you to subcategory V86.99-. The Tabular List shows this code needs seven characters. A placeholder X is used for the 6th character, and the 7th character is A for the initial encounter. The complete code is V86.99XA. A child has a splinter under the right middle fingernail. What ICD- 10 - CM code is reported? - Correct Ans: ✔✔S60.452A Rationale: In the ICD- 10 - CM Alphabetic Index look for Splinter - see Foreign body, superficial, by site. The Alphabetic Index entry at Foreign body/superficial, without open wound/ finger(s)/middle guides you to subcategory S60.45-. In the Tabular List seven characters are needed to complete the code. The 6th character 2 indicates the right middle finger and the 7th character A indicates the initial encounter. There was no mention of laceration or puncture wound so the other codes are incorrect. Verify code selection in the Tabular List. A patient was referred to the radiology department for chronic low back pain. The radiology report indicated there was no marrow

abnormality identified and the conus medullaris was unremarkable. Additional findings include: L4-L5: There is a minor diffusely bulging annulus at L4-L5. A small focal disc bulge is seen in far lateral position on the left at L4-L5 within the neural foramen. No definite encroachment on the exiting nerve root at this site is seen. No significant spinal stenosis is identified. L5-S1: There is a diffusely bulging annulus at L5-S1, with a small focal disc bulge centrally at this level. There is minor disc desiccation and disc space narrowing at L5-S1. No significant spinal stenosis is seen at L5-S1. The final diagnosis is minor degenerative disc disease at L4-L5 and L5-S1, as described. What ICD- 10 - CM code(s) is/are reported? - Correct Ans: ✔✔M51.36, M51. Rationale: Look in the ICD- 10 - CM Alphabetic Index for Degeneration, degenerative/intervertebral disc NOS/lumbar region directing you to code M51.36. Look in the ICD- 10 - CM Alphabetic Index for Degeneration, degenerative/intervertebral disc NOS/lumbosacral region directing you to code M51.37. Verify code selection in the Tabular List. The low back pain is a symptom of the degenerative disc disease and is not reported separately. Patient presents with no menses and positive pregnancy test but an ultrasound reveals no uterine contents. An embryo has implanted on the left ovary and this is treated with laparoscopic oophorectomy. What ICD- 10 - CM code is reported for this procedure? - Correct Ans: ✔✔O00. Rationale: For the diagnosis, look in the ICD- 10 - CM Alphabetic Index for Pregnancy/ovarian directing you to O00.20-. A 6 TH character is

required to identify laterality, 2 is assigned for the left ovary. In the Tabular List, there is an instructional note to use an additional code from category O08 to identify any associated complication. No complication is documented. Verify code selection in the Tabular List. What external cause code(s) are reported for a passenger involved in an MVA that lost control on the highway and hit a guardrail? - Correct Ans: ✔✔V47.6XXA, Y92. Rationale: In the ICD- 10 - CM External Cause of Injuries Index (after the ICD- 10 - CM Table of Drugs and Chemicals), look for Accident/transport/car occupant/passenger/collision (with)/stationary object (traffic), guiding you to V47.6-In the Tabular List a 7th character A is necessary for the initial encounter. You would use an additional external cause code when a place of occurrence (for example, home or parking lot) is documented. In this case, the location is documented as the highway. In the External Cause of Injuries Index, look for Place of occurrence/highway (interstate), guiding you to code Y92.411. Verify code selection in the Tabular List. A 14-year-old male patient was injured while skateboarding. The injuries included a displaced transverse fracture of the right femur shaft with multiple significant abrasions of the right thigh. What ICD- 10 - CM codes are reported? - Correct Ans: ✔✔S72.321A, V00.138A, Y93. Rationale: Look in the ICD- 10 - CM Alphabetic Index for Fracture, traumatic/femur, femoral/shaft/transverse (displaced) which directs

the coder to S72.32-. In the Tabular List, 7 characters are needed to complete the code. The complete diagnosis code is S72.321A because the 6th character is 1 for the right and this is the initial encounter for closed fracture identified with a 7th character A. ICD- 10 - CM guideline I.C.19.b.1 states separate codes for more superficial injuries of the same site (such as abrasions) should not be assigned. To find the external cause code look in the ICD- 10 - CM External Cause of Injuries Index for Accident/transport/pedestrian/conveyance (occupant)/skateboard, guiding you to V00.138. In the Tabular List the 7th character A is chosen for initial encounter. Next, you report an external cause code for the activity by looking for Activity/skateboarding in the Index to External Causes of injuries guiding you to Y93.51. There is no mention of the place of occurrence, so it is not coded. Verify code selection in the Tabular List. At 39 weeks gestation, a 26-year-old woman is admitted for precipitous labor and vaginally delivers a healthy baby girl. What ICD- 10 - CM codes are reported on the maternal record? - Correct Ans: ✔✔O62.3, Z37.0, Z3A. Rationale: The labor is precipitous. In the ICD- 10 - CM Alphabetic Index, look for Delivery (childbirth) (labor)/complicated/by/precipitate labor directing you to O62.3. ICD- 10 - CM guideline I.C.15.n.1 states that code O80 is reported for a full-term normal delivery of a single, healthy infant without any complications antepartum, during the delivery, or postpartum during the delivery episode. Code O80 is not to be reported with any other pregnancy complication code from chapter 15. In this case, O62.3 is reported for the complication and the normal delivery code (O80) is not reported. The outcome of delivery is also reported.

Look in the Alphabetic Index for Outcome of delivery/single/liveborn directing you to Z37.0. Code Z38.00 is only to be used on the newborn's record, not the maternal record. At the beginning of chapter 15, there is a note to use an additional code to report the weeks of gestation. The patient is 39 weeks gestation. Look in the Alphabetic Index for Pregnancy/weeks of gestation/39 weeks directing you to Z3A.39. Verify the code selection in the Tabular List. A male patient is here for his chemotherapy for metastatic carcinoma of the liver secondary to cancer of the right areola. What ICD- 10 - CM codes are reported? - Correct Ans: ✔✔Z51.11, C78.7, C50.021 Rationale: ICD- 10 - CM guideline I.C.2.e.2 states that if a patient admission/encounter is solely for the administration of chemotherapy, immunotherapy, or radiation therapy, assign code Z51.0 Encounter for antineoplastic radiation therapy, or Z51.11 Encounter for antineoplastic chemotherapy, or Z51.12 Encounter for antineoplastic immunotherapy as the first listed or principal diagnosis. In the ICD- 10 - CM Alphabetic Index look for Encounter (with health service) (for)/chemotherapy for neoplasm guiding you to code Z51.11. Next, look in the Alphabetic Index for Metastasis, metastatic/cancer/from specified site and you are directed to see Neoplasm, malignant, by site. In the ICD- 10 - CM Table of Neoplasms look for Neoplasm, neoplastic/liver and select the code from the Malignant Secondary column, guiding you to code C78.7. Next look for Neoplasm, neoplastic/areola and select the code from the Malignant Primary column or Neoplasm, neoplastic/breast/areola and select the code from the Malignant Primary column, guiding you to subcategory code C50.0-. In the Tabular List, the 5th character is reported for the sex of the patient. In this case the patient is a male

resulting in a 5th character of 2. The 6th character is for laterality; 1 is for right. The complete code is C50.021 for primary cancer of the right male areola. When assigning breast cancer codes make sure to select for the correct sex of the patient. The secondary cancer is listed first because the chemotherapy is directed to the secondary site per ICD- 10 - CM guideline I.C.2.b. Verify code selection in the Tabular List. A patient suffered postoperative left heart failure following repair of an abdominal aortic aneurysm. What ICD- 10 - CM code(s) is/are reported? - Correct Ans: ✔✔I97.131, I50.1 Rationale: In the ICD- 10 - CM Alphabetic Index look for Complication(s) (from) (of)/postprocedural/heart failure/following other surgery or Failure, failed/heart/postprocedural directing you to code I97.131. Verify the code selection in the Tabular List. There is a note under subcategory I97.13 to use additional code to identify the heart failure (I50.-). The patient is in left heart failure. In the Alphabetic Index look for Failure, failed/heart/left (ventricular) which instructs you to see Failure, ventricular, left. In the Alphabetic Index look for Failure, failed/ventricular/left which guides you to code I50.1. Verify the code selection in the Tabular List. You do not code the abdominal aortic aneurysm because the patient no longer has that condition. The patient has vaginitis three days after she was discharged from the hospital where she had a vaginal delivery of a healthy baby girl. What ICD- 10 - CM code is reported? - Correct Ans: ✔✔O86.13

Rationale: The postpartum period is also known as the puerperal period. In the ICD- 10 - CM Alphabetic Index look for Puerperal, puerperium (complicated by, complications)/vaginitis or Vaginitis/puerperal (postpartum) which directs you to code O86.13. Verify code selection in the Tabular List. A 28-year-old male was rushed to the ED after being found unconscious. Information from family members indicated the patient had left a suicide note and taken a large amount of LSD (a hallucinogenic). What ICD- 10 - CM codes are reported? - Correct Ans: ✔✔T40.8X2A, R40.20 Rationale: According to ICD- 10 - CM guideline I.C.19.e.5.b.ii, an overdose of a drug intentionally taken is reported as a poisoning. ICD- 10 - CM guideline I.C.19.e.5.b states that a poisoning is reported by first assigning the poisoning code (categories T36-T50), followed by a code for each manifestation. Any diagnosis of drug abuse or dependence is assigned as an additional code. Look in the ICD- 10 - CM Table of Drugs and Chemicals for LSD, and select the code from the Poisoning, Intentional Self-harm column which directs the you to T40.8X2-. In the Tabular List, 7th character A is selected for the initial encounter. The manifestation is unconsciousness. Look in the ICD- 10 - CM Alphabetic Index for Unconscious(ness) which states to see Coma which directs you to R40.20. In the Tabular List, Unconsciousness NOS is an inclusion term under R40.20. There is no mention of drug abuse or drug use outside of the suicide attempt. According to ICD- 10 - CM guideline I.C.19.e the codes for poisoning include the intent and the substance taken; no additional external cause code is required.

Ten days following a surgical below the knee amputation, the patient sees her provider. The provider notes that the amputation stump is not healing and is infected. What ICD- 10 - CM code(s) is/are reported? - Correct Ans: ✔✔T87.40 Rationale: In the ICD- 10 - CM Alphabetic Index look for Complication (s) (from) (of)/amputation stump (surgical) (late) NEC/infection or inflammation/lower limb guiding you to subcategory T87.4-. The Tabular List shows that a 5 th character is needed to complete the code. The documentation does not state which side has the amputation which makes 0 the correct 5th character. Code S88.119D is not reported because the encounter is not for a patient with a traumatic amputation. Verify code selection in the Tabular List. What ICD- 10 - CM coding is reported for a patient diagnosed with pressure ulcers on each heel, each heel displays bone involvement with evidence of necrosis and is identified as stage 4? - Correct Ans: ✔✔L89.614, L89.624 Rationale: Codes for pressure ulcers are determined by site, stage, and laterality. In this case, the patient has pressure ulcers on each heel, stage 4. Look in the ICD- 10 - CM Alphabetic Index for Ulcer/pressure/stage 4/heel L89.6-. In the Tabular List, a 5th character is required for laterality and 6th character is required for the stage. Report L89.614 for the right and L89.624 for the left. The stage is documented as stage 4.

A patient with age-related osteoporosis suffers a pathologic fracture to her right hip. She is being seen for this new fracture today. What ICD- 10 - CM coding is reported? - Correct Ans: ✔✔M80.051A Rationale: A combination code is reported for the pathological fracture and osteoporosis. In the ICD- 10 - CM Alphabetic Index, look for Osteoporosis/age related/with current pathological fracture/ilium M80.05-. In the Tabular List, this section includes osteoporosis with current pathological fracture and the subcategory code is reported for age-related osteoporosis with current pathological fracture of hip. A 6th character is required. Complete the code with 6th character 1 for right femur and 7th character A for initial encounter. A 47-year-old male was treated in the ED after being involved in a fight at a local pub. The patient sustained two lacerations, one to the left cheek and one to the left forearm. Abrasions were also on the left cheek. What ICD- 10 - CM codes are reported? - Correct Ans: ✔✔S01.412A, S51.812A, Y04.0XXA, Y92.29 Rationale: Look in the ICD- 10 - CM Alphabetic Index for Laceration/cheek (external) directing you to S01.41-. In the Tabular List a 6th character 2 is selected for the left cheek and 7th character A is selected for the initial encounter. Next, look in the Alphabetic Index for Laceration/forearm/left S51.812-. In the Tabular List a 7th character A is selected for the initial encounter. The abrasion on the face is not