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89 Cards in this Set

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CLOSED TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES, WITH MANIPULATION: INITIAL CARE PERFORMED BY THE ORTHOPEDIC SURGEON IN THE EMERGENCY DEPARTMENT.
813.23
CH 10 TEST YOUR KNOWLEDGE
A JUVENILE FALLS AND SUSTAINS A FRACTURE OF THE HUMERAL EPCONDYLE WHICH IS REDUCED ANATOMICALLY AND IS PERCUTANEOUSLY PIN.
812.43
CH 10 TEST YOUR KNOWLEDGE
PARONYCHIA OF FINGER
681.02
CH 10 TEST YOUR KNOWLEDGE
RECURRENT DISLOCATION OF THE SHOULDER
718.31
CH 10 TEST YOUR KNOWLEDGE
A 16-YEAR-OLD GIRL DEVELOPED A KELOID ON HER RIGHT EAR AFTER 3 WEEKS AFTER HAVING HER EARS PIERCED.
701.4
CH 10 TEST YOUR KNOWLEDGE
HEAT RASH.
705.1
CH 10 TEST YOUR KNOWLEDGE
TWO MONTH OLD CHILD WITH CONGENATAL DISLOCATION OF HIP.
754.30
CH 10 TEST YOUR KNOWLEDGE
LEG PAIN THAT IS LATE EFFECT OF AN OLD TIBIAL FRACTURE.
719.46, 905.4
CH 10 TEST YOUR KNOWLEDGE
LACERATION OF HAND FROM ASSAULT WITH A KNIFE.
882.0, E966
CH 10 TEST YOUR KNOWLEDGE
A 56-YEAR-OLD WOMAN WITH SEVERE RIGHT KNEE PAIN SAW AN ORTHOPEDIC SURGEON FOR EVALUATION. AFTER THE PHYSICIAN EXAMINED THE PATIENT AND TOOK X-RAYS OF THE RIGHT AND LEFT KNEES, A DIAGNOSIS OF DEGENERATIVE OSTEOARTHRITIS OF BOTH KNEES WAS MADE. THE PHYSICIAN PRESCRIBED A COURSE OF MEDICATION AND PHYSICAL THERAPY.
715.96
CH 10 TEST YOUR KNOWLEDGE
A PATIENT WITH CHRONIC BACK PAIN WAS REFERRED TO THE RADIOLOGY REPORT INDICATED THE FOLLOWING: NO MARROW SPACE ABNORMALITY; CONUS MEDULLARIS UNREMARKABLE; LL5, MINOR DIFFUSELY BULGING ANNULUS; SMALL FOCAL DISC BULGE IN THE FAR LATERAL POSITION ON THE LEFT AT L4-L5 WITHN THE NEURAL FORAMEN; NO DEFINITE ENCROACHMENT ON THE EXISTING NERVE ROOT SEEN AT THIS SITE; NO SIGNIFICANT SPINAL STENOSIS IDENTIFIED; L5-S1, DIFFUSELY BULGING ANNULUS, WITH A SMALL FOCAL DISC CENTRALLY AT THIS LEVEL; MINOR DISC DESICCATION AND DISC SPACE NARROWING AT L5-S1; NO SIGNIFICANT SPINAL STENOSIS AT L5-S1. THE FINAL DIAGNOSIS IS MINOR DEGENERATIVE DISC DISEASE AT L4-L5 AND L5-S1, AS DESCRIBED.
722.52
CH 10 TEST YOUR KNOWLEDGE
AN 18-MONTH-OLD BORN WITH HYPOSPADIAS PRESENTS TO THE HOSPITAL FOR HYPOSPADIAS CORRECTION.
752.61
CH 10 TEST YOUR KNOWLEDGE
A 24-YEAR-OLD PATIENT WAS SEEN IN THE OUTPATIENT DERMATOLOGY CLINIC AT THE LOCAL HOSPITAL. HIS COMPLAINTS WERE MODERATE ITCHING, WHICH THEN BECAME SEVERE (PRURITUS). HE ALSO NOTICED SMALL BLISTERS, REDNESS, AND SWELLING OF HIS LOWER LEGS. IT WAS DOCUMENTED THAT THE PATIENT HAD COME IN CONTACT WITH POISON IVY. THE PATIENT WAS DIAGNOSED WITH CONTACT DERMATITIS DUE TO POISION IVY.
692.6
CH 10 TEST YOUR KNOWLEDGE
A 16-MONTH-OLD PATIENT WAS SEEN IN THE PEDIATRIC CLINIC FOR A PERIANAL RASH. HE HAD BEEN GIVEN CEPHALEXIN, AS PRESCRIBED. AFTER EVALUATION, THE DIAGNOSIS WAS DERMATITIS DUE TO AN ADVERSE REACTION TO CEPHALEXIN. A TOPICAL CREAM WAS PRESCRIBED, AND CEPHALEXIN WAS DISCONTINUED.
691.0
CH 10 TEST YOUR KNOWLEDGE
A PATIENT WAS SEEN IN THE OUTPATIENT CLINIC FOR A PERIANAL RASH. HE HAD BEEN GIVEN CEPHALEXIN, AS PRESCRIBED. AFTER EVALUATION, THE DIAGNOSIS WAS DERMATITIS DUE TO AN ADVERSE REACTION TO CEPHALEXIN. A TOPICAL CREAM WAS PRESCRIBED, AND CEPHALEXIN WAS DISCONTINUED.
702.0
CH 10 TEST YOUR KNOWLEDGE
TRAUMATIC ARTHRITIS FOLLOWING FRACTURE OF THE LEFT ANKLE THREE YEARS AGO.
716.7, 905.4
CH 10 TEST YOUR KNOWLEDGE
LEG PAIN FROM OLD FRACTURE OF FEMUR
719.48, 905.3
CH 10 TEST YOUR KNOWLEDGE
FOREIGN BODY (STEEL) PENETRATION OF THE EYEBALL AND LACERATION OF THE PERIOCULAR AREA (SKIN).
871.6, 870.0, E914
CH 10 TEST YOUR KNOWLEDGE
A PATIENT WITH DIFFICULTY WITH SHOULDER FUNCTION AND DELTOID MUSCLE FUNCTION IS IN THE HOSPITAL RADIOLOGY DEPARTMENT FOR A LEFT SHOULDER ARTHROGRAM TO DETERMINE IF THERE IS A CUFF DEFECT. THE RADIOLOGIST DIAGNOSED THE PATIENT WITH ROTATOR CUFF SYNDROME.
726.10
CH 10 TEST YOUR KNOWLEDGE
A PATIENT WITH A 4.1-CM INFECTED SEBACEOUS CYST ON THE BACK AND A 2.5-CM INFECTED SEBACEOUS CYST ON THE NECT UNDERGOES SURGICAL EXCISION IN THE DERMATOLOGIST OFFICE.
706.2
CH 10 TEST YOUR KNOWLEDGE
A pregnant woman in her late third trimester sustains a complicated fracture of the skull during a car crash. As a result of her injuries, she goes into labor and the newborn is delivered in respiratory distress
760.5, 770.89
CH 11 POWERPOINT, SLIDE 5

Alphabetic Index: Maternal condition, affecting fetus or newborn  Injury 760.5
Tabular List: 760.5 Maternal injury affecting fetus or newborn
Alphabetic Index: Distress  respiratory  Fetus or newborn 770.8
Tabular List: 770.8 Other respiratory problems after birth
Correct codes: 760.5, 770.89
An infant is born prematurely at 26 weeks’ gestation and weighs 710 g. The physician assesses the infant as being extremely immature.
765.02, 765.23
CH 11 POWERPOINT, SLIDE 7

Alphabetic Index: Prematurity  Extreme 765.0
Tabular List: 765.0 Extreme immaturity (5th digit – for birth weight) 765.02
Note in category: use additional code for weeks of gestation (765.20-765.29)
A newborn was diagnosed with a navel infection due to tetanus bacillus (tetanus omphalitis) caused by use of accidental non-sterile instruments during delivery.
771.3
CH 11 POWERPOINT, SLIDE 9

Alphabetic Index: Omphalitis (congenital) (newborn)  tetanus 771.3
Tabular List: Tetanus neonatorum  Tetanus omphalitis 771.3
A patient was referred to a cardiologist by her family practitioner with symptoms of generalized fatigue and intermittent chest pain. After an electrocardiogram was performed, the cardiologist could not find any abnormalities and ordered a stress test to rule out any cardiac involvement.
786.50, 780.79
CH 11 POWERPOINT, SLIDE 14

Alphabetic Index:
*Pain -> chest (central) 786.50.
*Fatigue -> general 780.79

Tabular List:
*786.5 Chest pain -->786.50 Chest pain unspecified
*780.7 Malaise and fatigue --> 780.79 Other malaise and fatigue
CLOSED TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES, WITH MANIPULATION; INITIAL CARE PERFORMED BY THE ORTHOPEDIC SURGEON IN THE EMERGENCY ROOM OF THE LOCAL HOSPITAL.
no answer yet
CH 11 TEST YOUR KNOWLEDGE
A patient has a fracture of the humerus.
812.20
CH 11 POWERPOINT, SLIDE 24

Alphabetic Index:
Fracture  Humerus (closed) 812.20

Tabular List:
812.2 Fracture of humerus, shaft or unspecified part, closed 812.20, Fracture of humerus, shaft or unspecified part, closed, unspecified part of humerus
A patient is diagnosed with open fractures the tibia, fibula, and ankle due to a fall from a scaffold.
823.92, 824.9
CH 11 POWERPOINT, SLIDE 26

Alphabetic Index: Fracture  Tibia  with fibula  Open 823.92

Tabular List: 823.92 Open fracture of the tibia and fibula, unspecified part
Alphabetic Index: Fracture  Ankle  Open 824.9
Tabular List: 824.9 Fracture of ankle, unspecified part, open
A patient visits his internist for his 3-month follow-up visit.
He has been treated for hypertension for more than 10
years. The patient’s current blood pressure is 140/100 mm
Hg. A problem-focused history and exam are performed
and the physician adjusts the patient’s medication, reviews
previous blood pressure readings, and asks the patient to
follow up in 2 months. The Documentation indicates
hypertension without good control.
401.9
Hypertension, unspecified
CH 08 POWERPOINT, SLIDE 17
Hypertension Table

Alphabetic Index: Hypertension
(uncontrolled)  Unspecified 401.9

Tabular List: 401.9  Hypertension, unspecified
A 60-year-old patient is admitted to the hospital after suffering
from acute pain and collapsing at home. The emergency
department physician performs a comprehensive history and
exam, obtaining most of the patient’s history from the family.
This is the first episode of this nature that the patient has
experienced. The patient is transferred to the coronary care unit
in the hospital. A cardiologist is asked to take over the patient’s
care. The cardiologist examines the patient in the coronary care
unit and determines that the patient suffered an acute myocardial
infarction of the anterolateral wall.
410.01
CH 08 POWERPOINT, SLIDE 20
Acute Myocardial Infarction (410)

Alphabetic Index: Infarct, infarction  Myocardium, myocardial 410.9 
Anterolateral (wall) 410.0 (5th)

Tabular List: 410.0 Acute myocardial infarction of anterolateral wall
A 62-year-old female patient with a history of angina returns to her family physician for a 6-month follow-up visit. The patient’s complete history is reviewed and updated by the nurse. The physician performs a detailed examination and documents anginal syndrome as the primary diagnosis.
413.9
Other and unspecified angina pectoris
CH 08 POWERPOINT, SLIDE 23
Angina (413)

Alphabetic Index:
Angina (attack) (cardiac)(chest) (effort) (heart) (pectoris) (syndrome) 413.9

Tabular List: 413.9 Other and unspecified angina pectoris
(includes anginal syndrome)
An 84-year-old male discharged home from rehabilitation setting after cerebrovascular accident (CVA) and benign hypertension with ASHD of the native coronary arteries, requiring warfarin sodium. The hypertension is controlled adequately. Home health agency is providing weekly nursing visit, obtaining blood samples for prothrombin time measurements. The patient is progressing well with physical and occupational therapies. Nutrition seems adequate.
414.01, 401.1

ASHD - Arteriosclerotic heart disease
CH 08 POWERPOINT, SLIDE 25
Coronary Artery Disease (414)

Alphabetic Index: Arteriosclerosis, arteriosclerotic  coronary  native artery, 414.01

Tabular List: 414.01  Coronary atherosclerosis of native coronary artery

Because hypertension is also a diagnosis identified in the example, it must be coded as well
Alphabetic Index:
Hypertension  Benign 401.1

Tabular List: Hypertension 401.  Benign, 401.1
A patient is diagnosed with congestive heart failure.
428.0
Heart Failure
CH 08 POWERPOINT, SLIDE 27
Heart Failure (428)

Alphabetic Index: Failure  Congestive 428.0

Tabular List: 428.0 Heart Failure
A patient is diagnosed with congestive heart failure after cardiac surgery.
429.4
Functional disturbances following cardiac surgery
CH 08 POWERPOINT, SLIDE 28
Heart Failure (428)

Alphabetic Index:
Failure  Heart  Following  Cardiac surgery 429.4

Tabular List: 429.4 Functional disturbances following cardiac surgery
A 72-year-old woman suffered an acute right CVA resulting in a left-sided spastic hemiplegia. Although she can move her left arm, she has no functional use of it, as her increased muscle tone results in a flexion synergy in which she adducts her shoulder, flexes her elbow, and pulls her hand into a tight fist. To diminish the spasticity during her daily activities, the provider applies deep pressure to the patient’s bicep. The provider then internally rotates the patient’s upper arm, extends the elbows, pronates the forearm and extends the patient’s fingers and thumb. This combination of movements releases the spasm, and with manual guiding from the provider, the patient is able to practice grasping, holding and releasing large objects.
436
Acute, but ill-defined, cerebrovascular disease
CH 08 POWERPOINT, SLIDE 31-32
Cerebrovascular Disease (430-438)

Alphabetic Index: disease  cerebrovascular  acute 436

or

Alphabetic Index: stroke  apoplectic (see also Disease cerebrovascular, acute  (acute) 436

Tabular List: 436 Acute but ill-defined, cerebrovascular disease

Alphabetic Index: hemiplegia  due to  cerebrovascular lesion (see also Disease, cerebrovascular, acute) 436


The Alphabetic Index refers back to the code for CVA, 436. An additional code is not used for the hemiplegia because is the effect of the CVA.
A 16-year-old girl visits her family physician with complaints of sore throat, chronic cough, sneezing, and pain in the ears and nose. After an expanded problem-focused history and examination, her family physician diagnoses the condition as acute sinusitis due to an unknown fungus.
461.9, 117.9

Remember to code infectious organisms when coding diseases of the respiratory system.
CH 08 POWERPOINT, SLIDE 36
Acute Respiratory Infections (460-466)

Tabular List: 461.9 Acute sinusitis, unspecified Infectious organism 117.9, Other and unspecified mycoses
A 7-year-old patient visits his family physician. His mother says that her son is complaining of a sore throat and ear pain and has been running a temperature of 100 degrees Fahrenheit for more than 3 days. He has had previous episodes of tonsillitis and adenoiditis. After a detailed history and examination, the physician diagnoses a recurrence of tonsillitis and adenoiditis, which have become chronic. The physician prescribes an oral antibiotic for the patient and discusses removal of the tonsils and adenoids when the infection has subsided. The patient is scheduled to return to the office in 1 week for a recheck.
474.02
CH 08 POWERPOINT, SLIDE 38
Other Diseases of the Respiratory Tract (470-478)

Alphabetic Index: Adenoiditis  Chronic With tonsillitis 474.02

Tabular List: 474.02 Chronic tonsillitis and adenoiditis
A 30-year-old established patient visits her family physician with complaints of fever, chills, and sore throat. The physician performs an expanded problem-focused history and examination, and suspects pneumonia. To confirm the diagnosis, the physician orders posteroanterior and lateral chest X-rays, collects sputum, and orders a complete blood cell count.

The test results are positive for pneumonia caused by Staphylococcus aureus.
482.41
CH 08 POWERPOINT, SLIDE 40
Pneumonia and Influenza (480-487)

Alphabetic Index: Pneumonia  Due to Staphylococcus  aureus 482.41

Tabular List: 482.41 Pneumonia due to Staphylococcus aureus
A patient is diagnosed with pneumonia due to Rickettsia
083.9, 484.8
CH 08 POWERPOINT, SLIDE 41
Pneumonia and Influenza (480-487)

Alphabetic Index: Pneumonia  due to rickettsia 083.9 [484.8]

Tabular List: 083.9 Rickettsiosis, unspecified 484.8 Pneumonia in other infectious diseases classified elsewhere
A 35-year-old patient visits his physician with complaints of sore throat, runny nose, coughing, congestion, and overall aching. During the examination, the patient mentions he forgot to get his flu shot this year. After an expanded problem-focused history and examination, the physician diagnoses influenza with tracheitis.
487.1
CH 08 POWERPOINT, SLIDE 43
Pneumonia and Influenza (480-487)

Alphabetic Index: Influenza, influenza 487.1 with  Tracheitis 487.1

Tabular List: 487.1 Influenza with other respiratory manifestations
A 35-year-old patient fell ill 2 days after returning from a trip to the Far East. She visits her family physician with cough, headache, and severe shortness of breath. A chest x-ray was ordered which confirmed the presence of infiltrates indicative of pneumonia. After a comprehensive history and examination, the physician diagnosed the patient with pneumonia due to SARS.
480.3

Coding Tip:
When patient has been exposed to SARS, but NO evidence in laboratory findings indicates the disease is present
Code with V01.82 – Exposure to SARS-associated coronavirus
CH 08 POWERPOINT, SLIDE 46
Pneumonia and Influenza (480-487)


Alphabetic Index: Pneumonia  due to SARS-associated coronavirus  480.3

Tabular List: 480.3 Pneumonia due to SARS-associated coronavirus
A 66-year-old male with decompensated COPD, hypertension and a 40-pack-year of smoking with a 3-cm peripheral nodule in the right upper lobe is scheduled for a diagnostic thoracoscopy and biopsy using a left lateral position. Anesthesia with an inhalation agent and muscle relaxant, double-lumen endotracheal tube and arterial blood pressure monitoring is planned.
491.21

COPD - chronic obstructive pulmonary disease
CH 08 POWERPOINT, SLIDE 49
COPD and Allied Conditions (490-496)

Alphabetic Index: pulmonary  see condition  disease  pulmonary  obstructive (diffuse)  with  bronchitis (chronic)  acute exacerbation 491.21

Tabular List: 491.21 Obstructive chronic bronchitis, with (acute) exacerbation
A 32-year-old female patient visits a pulmonologist because she has experienced three asthma attacks during a 1-week period. She has experienced symptoms, of wheezing, coughing and shortness of breath. Neither her oral medication nor her inhaler seems to help much. The physician performs an comprehensive history and examination, reviews the previous patient notes, and decides to admit the patient to the hospital for intubation, ventilator and medication management. The physician diagnoses the patient with asthma with status asthmaticus
493.91
CH 08 POWERPOINT, SLIDE 51
Asthma (493)

Alphabetic Index: Asthma, asthmatic (bronchial) (catarrh) (spasmodic) 493.9

Tabular List: 493.9 Asthma, unspecified  493.91 Asthma, unspecified, with status asthmaticus
A 47-year-old woman develops acute respiratory distress syndrome after abdominal surgery
518.5
CH 08 POWERPOINT, SLIDE 53
Acute Respiratory Distress Syndrome (518)

Alphabetic Index: Syndrome  Respiratory distress  Adult  (following shock, surgery, or trauma) 518.5

Tabular List: 518.5 Pulmonary insufficiency following trauma and surgery
A 74-year-old male was admitted to the emergency department with symptoms of shortness of breath and disorientation. The ER physician examined the patient and called a pulmonologist in for a consult. The patient has a history of emphysema and COPD with chronic bronchitis. After examination the pulmonologist diagnosed the patient with acute respiratory failure.
518.81
CH 08 POWERPOINT, SLIDE 55
Acute Respiratory Failure

Alphabetic Index: failure  respiration, respiratory  518.81
Tabular List: 518.81 Acute respiratory failure
A patient presented with severe pain in the mouth. After the physician examined the patient and x-rays were taken, the patient was diagnosed with sialodocholithiasis (calculus of salivary gland).
527.5
CH 09 POWERPOINT, SLIDE 05
Diseases of the Oral Cavity and Salivary Glands (520-529)

Alphabetic Index: Calculus  salivary (duct) (gland) 527.5

Tabular List: 527.5 Calculus of salivary gland or duct
A worried mother brought her two-year-old daughter to the family physician. The mother stated the child was drooling, had been running a slight fever, and she noticed sores in the child’s mouth. After a detailed history and examination, the physician diagnosed the patient with ulcerative stomatitis and prescribed antiviral medication. The physician asked the mother to bring the child for a follow-up visit in 2 weeks or call sooner if the symptoms were not relieved.
528.00
CH 09 POWERPOINT, SLIDE 07
Diseases of Oral Soft Tissues (528)

Alphabetic Index: Stomatitis  Ulcerative 528.00

Tabular List: 528.00 Stomatitis  Ulcerative
A patient with a history of gastrointestinal acid reflux disease returns to his gastroenterologist for a follow-up exam. The patient has been taking (Omeprazole) Prilosec for 6 months, with little relief. The patient missed the previous appointment 3 months ago. After a detailed history and examination, the physician schedules the patient for a diagnostic endoscopy to be performed the same day. After the procedure, the physician determines that the patient’s condition has now worsened and diagnoses reflux esophagitis.
530.11
CH 09 POWERPOINT, SLIDE 09
Diseases of Oral Soft Tissues (528)

Alphabetic Index: Esophagitis  Reflux 530.11

Tabular List: 530.11 Reflux esophagitis
A 45-year-old male patient with esophageal reflux was admitted from the emergency department to the hospital with dysphagia, wheezing and hematemesis. A gastroenterologist was contacted to see the patient. The physician was unable to establish a diagnosis based on the exam of the patient, and performed a diagnostic endoscopy, which revealed acute esophagitis. In addition, the physician diagnosed the patient with an esophageal ulcer that was due to constant ingestion of aspirin
530.12 (first-listed),530.20 (secondary)
CH 09 POWERPOINT, SLIDE 11
Diseases of the Esophagus, Stomach, and Duodenum (530-538)

1) Alphabetic Index: Esophagitis  acute 530.12

Tabular List: 530.12 Acute esophagitis

2)Alphabetic Index: Ulcer  esophagus (peptic)  due to ingestion  aspirin 530.20
Tabular List: 530.20 Ulcer of esophagus without bleeding
A 50-year-old woman with chronic dysphagia and recurrent GERD undergoes endoscopic evaluation. The scope is advanced from the esophagus into the stomach and duodenum to complete the evaluation with particular attention to the gastroesophageal junction. The physician diagnosed the patient with Barrett’s esophagus.
530.85
CH 09 POWERPOINT, SLIDE 11
Diseases of the Esophagus, Stomach, and Duodenum (530-538)

Alphabetic Index: Barrett’s syndrome or ulcer  (chronic peptic ulcer of esophagus) 530.85

Tabular List: 530.85, Barrett’s esophagus
A 42-year-old patient with a history of gastric ulcers arrives at the emergency department (ED) with complaints of nausea, vomiting, and rectal bleeding. The ED physician contacts the general surgeon on call, who diagnoses the patient with acute gastric ulcer perforation with bleeding. Patient is taken to surgery for repair of the perforated ulcer.
531.20
CH 09 POWERPOINT, SLIDE 15
Ulcers (531-534)

Alphabetic Index: Ulcer  gastric – see Ulcer, stomach Ulcer, stomach (eroded) (peptic) (round)  acute  with  perforation 531.1 and hemorrhage 531.2

Tabular List: 531.2, Acute gastric ulcer with hemorrhage and perforation 531.20, Acute gastric ulcer with hemorrhage and perforation without mention of obstruction
A 65-year-old male presented with the inability to eat orally. Attempts to relieve the obstruction by flexible endoscopy, dilatation, and laser therapy are unsuccessful. The patient is malnourished and needs enteral nutritional support. The decision is made to perform a laparoscopic feeding gastrostomy on February 16. He is discharged 2 days postoperatively with instructions for wound care and gastrostomy feeding techniques. On February 22, the patient is back in the hospital with a sudden onset of spiking fever and chills. The patient is transferred to the critical care unit, and intravenous fluids are given to fight the septicemia due to a Staphylococcus infection
536.41, 038.10
CH 09 POWERPOINT, SLIDE 15
Disorders of Function of Stomach (536)

Alphabetic Index: Gastrostomy  infection  536.41
Tabular List: 536.41  Infection of Gastrostomy

The septicemia and staphylococcal infection must be coded as well

Alphabetic Index: Septicemia, septicemic (generalized) (suppurative)  with staphylococcal 038.10
Tabular List: 038.10 Staphylococcal septicemia, unspecified
A 50-year-old patient visits his family physician complaining of nausea and abdominal pain that is dull, but sometimes sharp. The physician performs a detailed history and examination. The physician refers the patient to a general surgeon who immediately sends him to the hospital and performs an appendectomy the same day. The patient is released the following day. The documented diagnosis indicates acute appendicitis with peritonitis.
540.0, Acute appendicitis with generalized peritonitis
CH 09 POWERPOINT, SLIDE 20
Appendicitis (540-543)

Alphabetic Index: Appendicitis  Acute  with  Perforation, peritonitis, or rupture 540.0
Tabular List: 540.0 Acute appendicitis with generalized peritonitis
A 46-year-old patient is diagnosed with a paraesophageal hiatal hernia with obstruction.
552.3
CH 09 POWERPOINT, SLIDE 25
Other Hernia of the Abdominal Hernia (551-553)

Alphabetic Index: Hernia  Hiatal (esophageal) (sliding)  with  obstruction 552.3

Tabular List: 552.3 Diaphragmatic hernia with obstruction
A 41-year-old established patient visits his family physician with complaints of diarrhea, gas, cramping, and bloating. The patient has a history of irritable bowel syndrome and diverticulitis. A problem-focused history and examination are performed and the physician’s documentation indicates the diagnosis is spastic colon with diverticulitis.
564.1, 562.11
CH 09 POWERPOINT, SLIDE 27
Noninfectious Enteritis and Colitis (555-558)

Alphabetic Index: Spasm, spastic, spasticity  Colon 564.1
Tabular List: 564.1, Irritable bowel syndrome, irritable colon
CH 09 POWERPOINT, SLIDE 27
Noninfectious Enteritis and Colitis (555-558)

Alphabetic Index: Diverticulitis (acute) – see also diverticula 562.11
Tabular List: 562.11, Diverticulitis of colon (without mention of hemorrhage)
A 58-year-old patient is experiencing severe diarrhea with negative stool cultures. Her physician recommends a colonoscopy. With the patient under IV sedation, the colonoscope is inserted into the rectum and advanced to the colon and beyond the splenic flexure, maneuvered through the hepatic flexure, and moved down the ascending colon to the rectum. The appendiceal orifice is visualized. The ileocecal valve is entered and approximately 10 cm of terminal ileum is visualized and photographed; it is within normal limits. The scope is withdrawn from the right colon and pulled back toward the transverse, descending, sigmoid, and rectum; all are adequately visualized, and there is no active colitis. Two rectal polyps are excised by snare technique and sent to pathology; Postoperative diagnosis: is benign rectal polyps with no active colitis
569.0
CH 09 POWERPOINT, SLIDE 29
Other Diseases of Intestines and Peritoneum (560-569)

Alphabetic Index: Polyp, polypus  Rectum (nonadenomatous) 569.0

Tabular List: 569.0 Anal and rectal polyp, NOS
A 28-year-old male presents with a history of an intermittent fever, jaundice, and vague upper right quadrant fullness. Computed tomography scan of the abdomen reveals a cystic lesion near the mid-portion of the common bile duct and no evidence of metastatic disease. Preoperative endoscopic retrograde cholangiopancreatography (ERCP) confirms a small calculus of the cystic duct. At laparotomy, the calculus is excised and frozen section reveals no adenocarcinoma. A primary extrahepatic common duct repair is performed over a T-tube.
574.20, Calculus of gallbladder without mention of cholecystitis or obstruction
A 54-year-old hypertensive male with hypertensive chronic kidney disease is in end stage renal failure requiring dialysis. His lifestyle has him frequently eating at restaurants. There are remarkable changes in his food intake from day to day and his phosphorus level is rarely controlled. His blood pressure is not well controlled with medication and he has malignant hypertension.
403.01, 585.6
CH 09 POWERPOINT, SLIDE 47
Kidney Disease

Alphabetic Index: Hypertension  with chronic kidney failure (and sclerosis) malignant, 403.01 Failure  kidney  end stage 585.6

Tabular List: 403 Hypertensive chronic kidney disease  403.0 Malignant  403.01  with renal failure 585.6 End stage Renal disease (ESRD)
A 64-year-old male with type I diabetes has been receiving hemodialysis for 1 month. He frequently experiences chest pain and headaches and is mildly noncompliant with diet. He has occasional problems with his fistula and often requires a longer session for fluid control. He is diagnosed with insulin-dependent diabetic nephropathy
250.41, 583.81
CH 09 POWERPOINT, SLIDE 49
Renal Disease

Alphabetic Index: Nephropathy diabetic 250.4 [583.81]

Tabular List: 250.4 indicates insulin dependent not stated as uncontrolled 250.41

583.81 Nephrotic syndrome in diseases classified elsewhere

Code first underlying disease as: diabetes mellitus (250.4..)
A 57-year-old female presents after having a routine mammogram, which shows a 1.5 cm ill-defined mass in the left breast, and an ultrasound, in which the mass is found to be heterogenous and solid. A histologic diagnosis is indicated. To more accurately discuss her diagnosis and treatment options, the decision is made, with the patient’s consent, to perform an image-guided percutaneous needle core breast biopsy, with imaging guidance. A biopsy is performed and the patient is diagnosed with fibrocystic breast disease.
610.1
CH 09 POWERPOINT, SLIDE 56
Disorders of Breast (610-611)

Alphabetic Index: Fibrocystic  disease breast  610.1

Tabular List: 610 Benign mammary of dysplasias
610.1 Diffuse cystic mastopathy Fibrocystic disease of breast
An obstetrician sees a pregnant woman at 28 weeks gestation for persistent pain in her left ear that started 3 weeks ago and has gotten progressively worse. The obstetrician examines the patient, determines that she has acute otitis media (382.9), and places her on appropriate medication therapy. The otitis media is not related to her pregnancy.
382.9, V22.2
CH 09 POWERPOINT, SLIDE 61
Complications of Pregnancy

Acute otitis media, first listed diagnosis;and use V22.2 (pregnancy, incidental state, secondary diagnosis
A patient presents with severe abdominal pain and amenorrhea. It is determined that the patient has a ruptured intrauterine tubal pregnancy and she is taken to surgery immediately.
633.11
CH 09 POWERPOINT, SLIDE 73
Complications of Pregnancy

Alphabetic Index: Pregnancy  Tubal (with rupture) 633.10

Tabular List: 633.10 Tubal pregnancy without uterine pregnancy
633.11 Tubal pregnancy with intrauterine pregnancy
A patient presents with severe abdominal pain and amenorrhea. It is determined that the patient has a ruptured intrauterine tubal pregnancy and she is taken to surgery immediately. The patient went into septic shock 1 hour after surgery.
633.11, 639.5
CH 09 POWERPOINT, SLIDE 75
Complications of Pregnancy

Alphabetic Index: Pregnancy  Tubal (with rupture) 633.10

Tabular List: 633.11, Tubal pregnancy with intrauterine pregnancy
639.5, Shock following abortion or ectopic and molar pregnancies
A 30-year-old patient in her 10th week of gestation has a complete spontaneous abortion (miscarriage). It is determined that the miscarriage occurred because of numerous uterine fibroids
634.72, 654.13
CH 09 POWERPOINT, SLIDE 78
Abortion/MIscarriage

1) Alphabetic Index: Abortion  Spontaneous 634.9 --> with specified complication 634.7

Tabular List: 634.72, Spontaneous abortion, complete

2) Alphabetic Index: Pregnancy  Complicated (by)  Tumor  Uterus (body) 654.1

Tabular List: 654.13 Tumors of body of uterus, antepartum condition or complication
A 27-year-old woman at 10 weeks of gestation presents with bleeding, abdominal pain, and cramps of sudden onset. The patient is diagnosed as having suffered an incomplete spontaneous abortion (miscarriage) and is scheduled for an immediate dilation and curettage to remove the retained products of conception. No other complications were noted.
634.91
CH 09 POWERPOINT, SLIDE 81
Abortion/MIscarriage

Alphabetic Index: Abortion  Spontaneous 634.9

Tabular List: 634.9 Spontaneous abortion, without mention of complication

The fifth-digit “1” identifies incomplete
A patient in her third trimester develops acute thyroiditis, that complicates her pregnancy during the antepartum period.
jhkjh
CH 09 POWERPOINT, SLIDE 83
Complications related to Pregnancy (640-649)

Alphabetic Index: Thyroiditis  Complicating pregnancy, childbirth, or puerperium 648.15

Tabular List: 648.1 Thyroid dysfunction (conditions classifiable to 240-246)

(A fifth digit of “3” indicates antepartum condition or complication: 648.13.)

Note instructs coder to use additional code to identify condition to provide more specificity
A liveborn single infant is delivered to a patient by lower-segment cesarean section because delivery was complicated by obstructed labor due to cephalopelvic disproportion.
660.11, 653.41, V27.0
CH 09 POWERPOINT, SLIDE 86
Norm Delivery, Other Indications for Care in Pregnancy, Labor and Delivery

Alphabetic Index: Delivery  Complicated (by) --> Cephalopelvic disproportion (normally formed fetus) 653.4

Tabular List: 653.41, Cephalopelvic disproportion NOS

Requires a fifth digit "1", delivered, with or without mention of antepartum condition

Code any obstructed labor (660.11)

Code Outcome of Delivery on maternal record

Alphabetic Index: Outcome of delivery -->single -->liveborn v27.0

Tabular list: V27.0 Single liveborn
A 23-year-old woman delivered a healthy boy in the hospital without complication.
V27.0
CH 09 POWERPOINT, SLIDE 90
Outcome of Delivery (V27)

Alphabetic Index: Normal -->Delivery --> 650 -->Outcome of delivery  single --> Liveborn V27.0

Tabular List: 650 normal delivery; V27.0 outcome of delivery, single liveborn
A 27-year-old patient suffered an atonic hemorrhage six hours after delivery
666.14
CH 09 POWERPOINT, SLIDE 92
Complications Occur Labor and Del (660-669)

Alphabetic Index: Hemorrhage  postpartum (atonic) after delivery of placenta 666.1 (5th)

Tabular List: 666.14 Other immediate postpartum hemorrhage, postpartum
After delivery, the patient had a postpartum fever for the past four hours. After the physician examined the patient, the patient was given medication to reduce the fever.
672.04
CH 09 POWERPOINT, SLIDE 92
Complications of Puerperium (670-677)

Alphabetic Index: Fever  puerperal, postpartum > 672.0

Tabular List: 672 > Pyrexia of unknown origin during puerperium > 672.0 > (fifth-digit indicates postpartum condition or complication)
A 40-year-old female presents to the OB/GYN five weeks after delivery of her fifth child via cesarean with complaints of swelling, chest pain, shortness of breath, fatigue and heart palpitations. The physician performs an ECG, noting poor R-wave progressions, intraventricular condition delay and ST- and T-wave changes. He orders a chest x-ray which reveals cardiomegaly with alveolar edema. The patient is diagnosed with postpartum cardiomyopathy and is admitted to the hospital and a course of medical treatment is prescribed.
674.54
Peripartum cardiomyopathy, postpartum condition or complication
CH 09 POWERPOINT, SLIDE 95
Complications of Puerperium (670-677)

Alphabetic Index: Cardiomyopathy  postpartum  674.5

Tabular List: 674.5 Peripartum cardiomyopathy
A 25-year-old patient is diagnosed with painful scarring due to an old second-degree perineal laceration that she suffered during her last pregnancy 2 years ago (late effect).
709.2, 677
CH 09 POWERPOINT, SLIDE 97
Complications of Puerperium (670-677)

1) Alphabetic Index: Scar, scarring  Painful 709.2

Tabular List: 709.2 Scar conditions and fibrosis of skin

2) Alphabetic Index: Late  effects (of)  pregnancy complication(s) 677
Tabular List: 677 Late effect of complication of pregnancy, childbirth, and the puerperium
A patient who has been bedridden for several months has developed a bedsore, an open pressure wound, on her buttocks. Her physician treats her decubitus ulcer (bedsore) appropriately.
Alphabetic Index: Ulcer, ulcerated, ulcerating, ul
707.05
CH 10 POWERPOINT, SLIDE 10
DISEASES SKIN AND SUBCUT TISSUE (700-709)

Alphabetic Index: Ulcer, ulcerated, ulcerating, ulceration, ulcerative  Decubitus (any site) 707.0 (5TH)

Tabular List: 707.0 Decubitus ulcer > buttocks
A 62-year-old female with a three-week history of hip pain is diagnosed with a fracture of the right femoral neck on the right. The problem is further complicated because the patient has multiple myeloma.
733.14, 203.00
CH 10 POWERPOINT, SLIDE 28
Pathological Fractures

1) Alphabetic Index: Fracture  pathologic > hip 733.14

Tabular List: 733.14 Pathologic fracture of neck of femur

2)Alphabetic Index: Myeloma (multiple) (plasma cell) (plasmacytic) 203.0

Tabular List: 203.0 Multiple myeloma  fifth-digit “0” indicates without mention of remission
A 37-year-old patient was previously treated by external fixation for a grade III left tibial fracture (823.90). There is now nonunion of the left proximal tibia and he is admitted for open reduction of tibia with bone grafting. Approximately 20 grams of cancellous bone was harvested from the iliac crest. The fracture site was exposed, the area of nonunion was osteotomized, cleaned, and repositioned. Interfragmentary compression was applied and three screws and the harvested bone graft was packed into fracture site.
733.82, 905.4
CH 10 POWERPOINT, SLIDE 30
Nonunion of Fracture

Alphabetic Index: Nonunion  fracture  733.82
Tabular List: 733.82 Nonunion of fracture
Alphabetic Index: Late effect(s) (of)  fracture  Extremity  lower  (injury classifiable to 821-827) 905.4
Tabular List: 905.4 Late effect of fracture of lower extremities
A pregnant woman in her late third trimester sustains a complicated fracture of the skull during a car crash. As a result of her injuries, she goes into labor and the newborn is delivered in respiratory distress.
760.5, 770.89
CH 11 POWERPOINT, SLIDE 5
Maternal Cause of Perinatal Morbidity

1) Alphabetic Index: Maternal condition, affecting fetus or newborn > Injury 760.5

Tabular List: 760.5 Maternal injury affecting fetus or newborn

2) Alphabetic Index: Distress  respiratory > Fetus or newborn 770.8

Tabular List: 770.8 Other respiratory problems after birth
A newborn was diagnosed with a navel infection due to tetanus bacillus (tetanus omphalitis) caused by use of accidental non-sterile instruments during delivery.
771.3
CH 11 POWERPOINT, SLIDE 9
Conditions Originating Perinatal Period

Alphabetic Index: Omphalitis (congenital) (newborn) >tetanus 771.3

Tabular List: Tetanus neonatorum > Tetanus omphalitis 771.3
A patient has a fracture of the humerus.
812.20
CH 11 POWERPOINT, SLIDE 24
Fractures

Alphabetic Index: Fracture  Humerus (closed) 812.20

Tabular List: 812.2 Fracture of humerus, shaft or unspecified part, closed 812.20, Fracture of humerus, shaft or unspecified part, closed, unspecified part of humerus
A patient is diagnosed with open fractures the tibia, fibula, and ankle due to a fall from a scaffold.
823.92, 824.9
CH 11 POWERPOINT, SLIDE 26
Fractures

1) Alphabetic Index: Fracture  Tibia  with fibula  Open 823.92
Tabular List: 823.92 Open fracture of the tibia and fibula, unspecified part
2) Alphabetic Index: Fracture  Ankle > Open 824.9
Tabular List: 824.9 Fracture of ankle, unspecified part, open
A girl dislocates her shoulder while playing volleyball at school.
813.00
CH 11 POWERPOINT, SLIDE 28
Dislocation

Alphabetic Index: Dislocation  Shoulder 813.00

Tabular List: 813.0 Dislocation of shoulder, closed 813.00 Dislocation of shoulder, closed, unspecified
A man is diagnosed with a second-degree burn on his left ear and first-degree burns on his chin and nose.
941.21
CH 11 POWERPOINT, SLIDE 36
Burns

Alphabetic Index:
Burn > Ear > Second degree 941.21 ;
Burn > Chin > First degree 941.14 ;
Burn > Nose > First degree 941.15

Tabular List:
All three burns are in same category (941 Burn on face, head, and neck). Therefore, code only for most severe – second-degree burn of ear, 941.21.)
A woman has a third-degree burn on her left thigh that has subsequently become infected, complicating the treatment of her burn.
945.36, 958.3
CH 11 POWERPOINT, SLIDE 38
Burns

1) Alphabetic Index: Burn  Thigh  Third degree 945.36

Tabular List: 945.36 Third degree burn of lower limb(s), thigh

2) Alphabetic Index: Infection  Posttraumatic NEC 958.3

Tabular List: 958.3 Posttraumatic wound infection, NEC
A patient receives a second-degree burn on the right ankle and a third-degree burn on the palm of the left hand when she picks up a hot pan, then drops it and it hits her right ankle.
944.35, 945.23
CH 11 POWERPOINT, SLIDE 40
Burns

1) Alphabetic Index: Burn > Ankle > Second degree 945.23

Tabular List: 945.23 Second degree burn of lower limb(s), ankle

2) Alphabetic Index: Burn > Palm(s) > Third degree 944.35
Tabular List: 944.35 Third degree burn of palm
A woman received multiple third-degree burns on both arms, totaling 18% of the total body surface area.
943.39, 948.11
CH 11 POWERPOINT, SLIDE 43
Burns - Body Surface

1) Alphabetic Index: Burn  Arm(s) > Multiple sites > Third degree 943.30

Tabular List: 943.30 Burn of the upper limb, except wrist and hand, third degree, upper limb, unspecified site

2) Alphabetic Index: Burn  Extent (percent of body  surface)  10-19 percent 948.1

Tabular List: 948 Burns classified according to body surface involved, 948.1, 10-19 percent of body surface, 948.11, 10-19 percent of body surface, third degree burn
A patient received accidental third-degree burns on multiple sites involving the hands and wrist due to a kitchen fire two years ago. Although the burns have healed, the patient has developed painful scarring as a late effect of these burns.
709.2, 906.6, E929.4
CH 11 POWERPOINT, SLIDE 45
Burns - Late Effect

Alphabetic Index: Scar, scarring  Painful 709.2
Tabular List: 709.2 Scar conditions and fibrosis of skin
Alphabetic Index: Late  Effect(s) (of)  Burn  Extremities NEC  Hand or wrist 906.6
Tabular List: 906.6 late effect of burn of wrist and hand
E Code Index: Late effect of  fire, accident caused by E929.4
Tabular List: E929.4 Late effects of accident caused by fire
malignant hypertension due to primary aldosteronism
405.09, 255.10
Ch 08 Ex 01, 01

1) Alpha Index: Hypertension (malignant) > due to > aldosteronism 405.0
9

2 ) Alpha Index: Aldosteronism (primary) 255.10
secondary, benign hypertention due to renal artery occlusion
593.81, 405.11
Ch 08 Ex 01, 03

1) Alpha Index: Occlusion > renal artery 593.81
2) Alpha Index: Hypertension > secondary > due to > occlusion > benign 405.11
chronic ateriosclerotic nephritis
403.90, 585.9
Ch 08 Ex 01, 05

2) Nephritis > arteriosclerotic 585.9

1) Hypertension > kidney > with > chronic kidney disease > unspecified > unspecifed 403.90
bilateral carotid occlusion
433.30
Ch 08 TYK 01

Alpha: Occlusion > artery > carotid > bilateral 433.3 (5th)

Tabular: 433.3 Mult and bilateral. 5th digit "0" - w/o mention of cerebral infarction
COPD w asthma in a 65-year-old male smoker.
493.20,
Ch 08 TYK 02

Alpha: asthma > with > chronic obstructive pulmonary disease 493.2 (5th)

History of > smoking (tobacco) V15.82

Tabular: