Icd 9 Cm 2009

Front 1

CLOSED TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES, WITH MANIPULATION: INITIAL CARE PERFORMED BY THE ORTHOPEDIC SURGEON IN THE EMERGENCY DEPARTMENT.

Back 1

813.23

Hint 1

CH 10 TEST YOUR KNOWLEDGE

Front 2

A JUVENILE FALLS AND SUSTAINS A FRACTURE OF THE HUMERAL EPCONDYLE WHICH IS REDUCED ANATOMICALLY AND IS PERCUTANEOUSLY PIN.

Back 2

812.43

Hint 2

CH 10 TEST YOUR KNOWLEDGE

Front 3

PARONYCHIA OF FINGER

Back 3

681.02

Hint 3

CH 10 TEST YOUR KNOWLEDGE

Front 4

RECURRENT DISLOCATION OF THE SHOULDER

Back 4

718.31

Hint 4

CH 10 TEST YOUR KNOWLEDGE

Front 5

A 16-YEAR-OLD GIRL DEVELOPED A KELOID ON HER RIGHT EAR AFTER 3 WEEKS AFTER HAVING HER EARS PIERCED.

Back 5

701.4

Hint 5

CH 10 TEST YOUR KNOWLEDGE

Front 6

HEAT RASH.

Back 6

705.1

Hint 6

CH 10 TEST YOUR KNOWLEDGE

Front 7

TWO MONTH OLD CHILD WITH CONGENATAL DISLOCATION OF HIP.

Back 7

754.30

Hint 7

CH 10 TEST YOUR KNOWLEDGE

Front 8

LEG PAIN THAT IS LATE EFFECT OF AN OLD TIBIAL FRACTURE.

Back 8

719.46, 905.4

Hint 8

CH 10 TEST YOUR KNOWLEDGE

Front 9

LACERATION OF HAND FROM ASSAULT WITH A KNIFE.

Back 9

882.0, E966

Hint 9

CH 10 TEST YOUR KNOWLEDGE

Front 10

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.

Back 10

715.96

Hint 10

CH 10 TEST YOUR KNOWLEDGE

Front 11

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.

Back 11

722.52

Hint 11

CH 10 TEST YOUR KNOWLEDGE

Front 12

AN 18-MONTH-OLD BORN WITH HYPOSPADIAS PRESENTS TO THE HOSPITAL FOR HYPOSPADIAS CORRECTION.

Back 12

752.61

Hint 12

CH 10 TEST YOUR KNOWLEDGE

Front 13

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.

Back 13

692.6

Hint 13

CH 10 TEST YOUR KNOWLEDGE

Front 14

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.

Back 14

691.0

Hint 14

CH 10 TEST YOUR KNOWLEDGE

Front 15

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.

Back 15

702.0

Hint 15

CH 10 TEST YOUR KNOWLEDGE

Front 16

TRAUMATIC ARTHRITIS FOLLOWING FRACTURE OF THE LEFT ANKLE THREE YEARS AGO.

Back 16

716.7, 905.4

Hint 16

CH 10 TEST YOUR KNOWLEDGE

Front 17

LEG PAIN FROM OLD FRACTURE OF FEMUR

Back 17

719.48, 905.3

Hint 17

CH 10 TEST YOUR KNOWLEDGE

Front 18

FOREIGN BODY (STEEL) PENETRATION OF THE EYEBALL AND LACERATION OF THE PERIOCULAR AREA (SKIN).

Back 18

871.6, 870.0, E914

Hint 18

CH 10 TEST YOUR KNOWLEDGE

Front 19

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.

Back 19

726.10

Hint 19

CH 10 TEST YOUR KNOWLEDGE

Front 20

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.

Back 20

706.2

Hint 20

CH 10 TEST YOUR KNOWLEDGE

Front 21

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

Back 21

760.5, 770.89

Hint 21

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: 770.8Other respiratory problems after birth
Correct codes: 760.5, 770.89

Front 22

An infant is born prematurely at 26 weeks’ gestation and weighs 710 g. The physician assesses the infant as being extremely immature.

Back 22

765.02, 765.23

Hint 22

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 codefor weeks of gestation (765.20-765.29)

Front 23

A newborn was diagnosed with a navel infection due to tetanus bacillus (tetanus omphalitis) caused by use of accidental non-sterile instruments during delivery.

Back 23

771.3

Hint 23

CH 11 POWERPOINT, SLIDE 9

Alphabetic Index: Omphalitis (congenital) (newborn)  tetanus 771.3
Tabular List: Tetanus neonatorum  Tetanus omphalitis 771.3

Front 24

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.

Back 24

786.50, 780.79

Hint 24

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

Front 25

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.

Back 25

no answer yet

Hint 25

CH 11 TEST YOUR KNOWLEDGE

Front 26

A patient has a fracture of the humerus.

Back 26

812.20

Hint 26

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 orunspecified part, closed, unspecified part of humerus

Front 27

A patient is diagnosed with open fractures the tibia, fibula, and ankle due to a fall from a scaffold.

Back 27

823.92, 824.9

Hint 27

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

Front 28

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.

Back 28

401.9
Hypertension, unspecified

Hint 28

CH 08 POWERPOINT, SLIDE 17
Hypertension Table

Alphabetic Index: Hypertension
(uncontrolled)  Unspecified 401.9

Tabular List: 401.9  Hypertension, unspecified

Front 29

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.

Back 29

410.01

Hint 29

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

Front 30

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.

Back 30

413.9
Other and unspecifiedangina pectoris

Hint 30

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 unspecifiedangina pectoris
(includes anginal syndrome)

Front 31

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.

Back 31

414.01, 401.1

ASHD - Arteriosclerotic heart disease

Hint 31

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 nativecoronary artery

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

Tabular List: Hypertension 401.  Benign, 401.1

Front 32

A patient is diagnosed with congestive heart failure.

Back 32

428.0
Heart Failure

Hint 32

CH 08 POWERPOINT, SLIDE 27
Heart Failure (428)

Alphabetic Index: Failure  Congestive 428.0

Tabular List: 428.0 Heart Failure

Front 33

A patient is diagnosed with congestive heart failure after cardiac surgery.

Back 33

429.4
Functional disturbances following cardiac surgery

Hint 33

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

Front 34

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 movementsreleases the spasm, and with manual guiding from the provider, the patient is able to practice grasping, holding and releasing large objects.

Back 34

436
Acute, but ill-defined, cerebrovascular disease

Hint 34

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.

Front 35

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.

Back 35

461.9, 117.9

Remember to code infectiousorganisms when coding diseases of therespiratory system.

Hint 35

CH 08 POWERPOINT, SLIDE 36
Acute Respiratory Infections (460-466)

Tabular List: 461.9 Acute sinusitis, unspecifiedInfectious organism 117.9, Other andunspecified mycoses

Front 36

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.

Back 36

474.02

Hint 36

CH 08 POWERPOINT, SLIDE 38
Other Diseases of theRespiratory Tract (470-478)

Alphabetic Index: Adenoiditis  Chronic With tonsillitis 474.02

Tabular List: 474.02 Chronic tonsillitis and adenoiditis

Front 37

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.

Back 37

482.41

Hint 37

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 toStaphylococcus aureus

Front 38

A patient is diagnosed with pneumonia due to Rickettsia

Back 38

083.9, 484.8

Hint 38

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

Front 39

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.

Back 39

487.1

Hint 39

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 withother respiratory manifestations

Front 40

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.

Back 40

480.3

Coding Tip:
When patient has been exposed toSARS, but NO evidence in laboratory findingsindicates the disease is present
Code with V01.82 – Exposure toSARS-associated coronavirus

Hint 40

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

Front 41

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.

Back 41

491.21

COPD - chronic obstructive pulmonary disease

Hint 41

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 chronicbronchitis, with (acute) exacerbation

Front 42

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 physiciandiagnoses the patient with asthma with status asthmaticus

Back 42

493.91

Hint 42

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

Front 43

A 47-year-old woman develops acute respiratory distress syndrome after abdominal surgery

Back 43

518.5

Hint 43

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

Front 44

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.

Back 44

518.81

Hint 44

CH 08 POWERPOINT, SLIDE 55
Acute Respiratory Failure

Alphabetic Index: failure  respiration, respiratory  518.81
Tabular List: 518.81 Acuterespiratory failure

Front 45

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).

Back 45

527.5

Hint 45

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 salivarygland or duct

Front 46

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.

Back 46

528.00

Hint 46

CH 09 POWERPOINT, SLIDE 07
Diseases of Oral Soft Tissues (528)

Alphabetic Index: Stomatitis  Ulcerative 528.00

Tabular List: 528.00 Stomatitis  Ulcerative

Front 47

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.

Back 47

530.11

Hint 47

CH 09 POWERPOINT, SLIDE 09
Diseases of Oral Soft Tissues (528)

Alphabetic Index: Esophagitis  Reflux 530.11

Tabular List: 530.11 Reflux esophagitis

Front 48

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

Back 48

530.12 (first-listed),530.20 (secondary)

Hint 48

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 esophaguswithout bleeding

Front 49

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.

Back 49

530.85

Hint 49

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

Front 50

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.

Back 50

531.20

Hint 50

CH 09 POWERPOINT, SLIDE 15
Ulcers (531-534)

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

Tabular List: 531.2, Acute gastric ulcerwith hemorrhage and perforation 531.20, Acute gastric ulcer with hemorrhage andperforation without mention of obstruction

Front 51

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

Back 51

536.41, 038.10

Hint 51

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 mustbe coded as well

Alphabetic Index: Septicemia, septicemic(generalized) (suppurative)  with staphylococcal 038.10
Tabular List: 038.10 Staphylococcal septicemia, unspecified

Front 52

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.

Back 52

540.0, Acute appendicitiswith generalized peritonitis

Hint 52

CH 09 POWERPOINT, SLIDE 20
Appendicitis (540-543)

Alphabetic Index: Appendicitis  Acute  with  Perforation, peritonitis, or rupture 540.0
Tabular List: 540.0 Acute appendicitiswith generalized peritonitis

Front 53

A 46-year-old patient is diagnosed with a paraesophageal hiatal hernia with obstruction.

Back 53

552.3

Hint 53

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 Diaphragmatichernia with obstruction

Front 54

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.

Back 54

564.1, 562.11

Hint 54

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 ofcolon (without mention of hemorrhage)

Front 55

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

Back 55

569.0

Hint 55

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

Front 56

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.

Back 56

574.20, Calculus of gallbladderwithout mention of cholecystitis or obstruction

Front 57

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.

Back 57

403.01, 585.6

Hint 57

CH 09 POWERPOINT, SLIDE 47
Kidney Disease

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

Tabular List: 403 Hypertensive chronickidney disease  403.0Malignant  403.01  with renal failure585.6 End stage Renal disease (ESRD)

Front 58

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

Back 58

250.41, 583.81

Hint 58

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: diabetesmellitus (250.4..)

Front 59

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.

Back 59

610.1

Hint 59

CH 09 POWERPOINT, SLIDE 56
Disorders of Breast (610-611)

Alphabetic Index: Fibrocystic  diseasebreast  610.1

Tabular List: 610 Benign mammary ofdysplasias
610.1 Diffuse cystic mastopathy Fibrocystic disease of breast

Front 60

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.

Back 60

382.9, V22.2

Hint 60

CH 09 POWERPOINT, SLIDE 61
Complications of Pregnancy

Acute otitis media, first listed diagnosis;and use V22.2 (pregnancy, incidental state, secondary diagnosis

Front 61

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.

Back 61

633.11

Hint 61

CH 09 POWERPOINT, SLIDE 73
Complications of Pregnancy

Alphabetic Index: Pregnancy  Tubal (with rupture) 633.10

Tabular List: 633.10 Tubal pregnancywithout uterine pregnancy
633.11 Tubal pregnancy with intrauterine pregnancy

Front 62

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.

Back 62

633.11, 639.5

Hint 62

CH 09 POWERPOINT, SLIDE 75
Complications of Pregnancy

Alphabetic Index: Pregnancy  Tubal (with rupture) 633.10

Tabular List: 633.11, Tubal pregnancy withintrauterine pregnancy
639.5, Shock following abortion or ectopic and molar pregnancies

Front 63

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

Back 63

634.72, 654.13

Hint 63

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 ofuterus, antepartum condition or complication

Front 64

A 27-year-old woman at 10 weeks of gestation presents with bleeding, abdominal pain, and crampsof 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.

Back 64

634.91

Hint 64

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

Front 65

A patient in her third trimester develops acute thyroiditis, that complicates her pregnancy during the antepartum period.

Back 65

jhkjh

Hint 65

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 antepartumcondition or complication: 648.13.)

Note instructs coder to use additional code to identify condition to provide more specificity

Front 66

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.

Back 66

660.11, 653.41, V27.0

Hint 66

CH 09 POWERPOINT, SLIDE 86
Norm Delivery, Other Indications for Care in Pregnancy, Labor and Delivery

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

Tabular List: 653.41, Cephalopelvic disproportion NOS

Requires a fifth digit "1", delivered, with orwithout 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

Front 67

A 23-year-old woman delivered a healthy boy in the hospital without complication.

Back 67

V27.0

Hint 67

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

Front 68

A 27-year-old patient suffered an atonic hemorrhage six hours after delivery

Back 68

666.14

Hint 68

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

Front 69

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.

Back 69

672.04

Hint 69

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)

Front 70

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.

Back 70

674.54
Peripartum cardiomyopathy, postpartum condition or complication

Hint 70

CH 09 POWERPOINT, SLIDE 95
Complications of Puerperium (670-677)

Alphabetic Index: Cardiomyopathy  postpartum  674.5

Tabular List: 674.5 Peripartum cardiomyopathy

Front 71

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).

Back 71

709.2, 677

Hint 71

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 complicationof pregnancy, childbirth, and the puerperium

Front 72

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

Back 72

707.05

Hint 72

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

Front 73

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.

Back 73

733.14, 203.00

Hint 73

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

Front 74

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.

Back 74

733.82, 905.4

Hint 74

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

Front 75

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.

Back 75

760.5, 770.89

Hint 75

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: 770.8Other respiratory problems after birth

Front 76

A newborn was diagnosed with a navel infection due to tetanus bacillus (tetanus omphalitis) caused by use of accidental non-sterile instruments during delivery.

Back 76

771.3

Hint 76

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

Front 77

A patient has a fracture of the humerus.

Back 77

812.20

Hint 77

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 orunspecified part, closed, unspecified part of humerus

Front 78

A patient is diagnosed with open fractures the tibia, fibula, and ankle due to a fall from a scaffold.

Back 78

823.92, 824.9

Hint 78

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

Front 79

A girl dislocates her shoulder while playing volleyball at school.

Back 79

813.00

Hint 79

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

Front 80

A man is diagnosed with a second-degree burn on his left ear and first-degree burns on his chin and nose.

Back 80

941.21

Hint 80

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.)

Front 81

A woman has a third-degree burn on her left thigh that has subsequently become infected, complicating the treatment of her burn.

Back 81

945.36, 958.3

Hint 81

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

Front 82

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.

Back 82

944.35, 945.23

Hint 82

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

Front 83

A woman received multiple third-degree burns on both arms, totaling 18% of the total body surface area.

Back 83

943.39, 948.11

Hint 83

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

Front 84

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.

Back 84

709.2, 906.6, E929.4

Hint 84

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

Front 85

malignant hypertension due to primary aldosteronism

Back 85

405.09, 255.10

Hint 85

Ch 08 Ex 01, 01

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

2 ) Alpha Index: Aldosteronism (primary) 255.10

Front 86

secondary, benign hypertention due to renal artery occlusion

Back 86

593.81, 405.11

Hint 86

Ch 08 Ex 01, 03

1) Alpha Index: Occlusion > renal artery 593.81
2) Alpha Index: Hypertension > secondary > due to > occlusion > benign 405.11

Front 87

chronic ateriosclerotic nephritis

Back 87

403.90, 585.9

Hint 87

Ch 08 Ex 01, 05

2) Nephritis > arteriosclerotic 585.9

1) Hypertension > kidney > with > chronic kidney disease > unspecified > unspecifed 403.90

Front 88

bilateral carotid occlusion

Back 88

433.30

Hint 88

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

Front 89

COPD w asthma in a 65-year-old male smoker.

Back 89

493.20,

Hint 89

Ch 08 TYK 02

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

History of > smoking (tobacco) V15.82

Tabular: