Instructions: Assign the most appropriate ICD-10-CM diagnosis code(s).
WK1 Question2 HP-216
1) Hearing loss, fever, swollen axillary lymph nodes, and infective otitis externa, left ear FILL IN BLANK
2) Focal epilepsy FILL IN BLANK
3) Type 2 diabetes mellitus without complication FILL IN BLANK
4) Personal history of thyroid cancer FILL IN BLANK
5) Shortness of breath FILL IN BLANK
6) Foot pain, plantar fasciitis FILL IN BLANK
7) Peripheral neuropathy due to type 2 diabetes mellitus FILL IN BLANK
8) Prostatitis FILL IN BLANK
9)Acute and chronic salpingo-oophoritis FILL IN BLANK 2 ANSWERS
10) Chlamydial pneumonia FILL IN BLANK
11) A 45-year-old male patient is admitted with complaints of fever, headache, fatigue, and a sore throat. This patient is also seen frequently in the HIV clinic. The patient is admitted for further evaluation. Laboratory testing reveals that the patient has toxoplasmosis. The patient’s CD4 cell count is 125, which is below the normal of 200. The patient is treated for several days with intravenous pyrimethamine and clindamycin. After 15 days, the patient is in slightly improved condition and will be followed at the clinic. Medications administrated intravenously will be continued by mouth after hospital discharge. Discharge diagnosis is disseminated toxoplasmosis due to AIDS.
Which code(s) are reported?
Responses
- B20
- 9, R51.9, R53.83, J02.9, B58.89
- 9, B20
- B20, B58.89
12)5-year-old female is seen in the emergency department (ED) with the main complaint of musculoskeletal pain. The patient has had this “all over” pain for over a year and has never seen a physician about it. Examination in the ED reveals that the patient has pain in her shoulders and lower back. She also reports difficulty sleeping due to the pain. The patient also has some mild edema of the extremities. She is admitted to rule out congestive heart failure and kidney failure, both of which could be a cause of the edema. Laboratory tests are all within normal range. Chest X-ray and shoulder X-ray are all normal per radiology reports. The patient is discharged after two days in the hospital with medications to alleviate pain and to help her sleep. Discharge diagnosis is musculoskeletal pain, likely fibromyalgia. Which ICD-10-CM inpatient facility diagnosis code(s) are reported?
Responses
- 0, M79.7
- 7
- 2, M25.519, M54.50
- 18, M54.2, M25.519, M54.50
13) Admission diagnoses include weight loss, hypotension, and weakness. Final diagnosis is adrenal hypofunction. Which ICD-10-CM inpatient facility diagnosis code is reported?
Responses
- 0
- 40
- 3
- 2
14) 25-year-old male patient is seen in the emergency department (ED) with the symptom of epigastric pain. The patient reports that he has had this pain for four weeks. In the ED, the patient vomits, but the pain is not relieved. The patient is admitted, and the following diagnostic tests are performed: complete blood count, urinalysis, and gastrointestinal x-ray series. Testing determines that the patient has acute pancreatitis. The patient is discharged in improved condition. Which ICD-10-CM inpatient facility diagnosis code is reported?
Responses
- 80
- 90
- 00
- 30
15) 16-year-old female patient is seen in the urgent care center of a hospital with the complaint of shortness of breath. Upon examination, the patient is found to be using accessory muscles to breathe. Pulse oximetry is placed on the patient, and arterial blood gases are monitored. The patient is given several nebulizer treatments. However, her breathing does not improve. She is admitted with the diagnosis of asthma. Upon admission, the patient receives intravenous corticosteroids, nebulizer treatments, and subcutaneous epinephrine. Her breathing does improve after this treatment. The patient is monitored for 24 hours and discharged. Discharge diagnosis is “asthma, status asthmaticus.” Which ICD-10-CM inpatient facility diagnosis code(s) are reported?
Responses
- 902
- 32
- 21
- 20, J45.22
16) A patient is admitted to Mingo River Hospital with the complaint of headaches and nosebleeds. The 67-year-old patient takes daily medication for arthritis. He is admitted with an elevated blood pressure of 185/100. While in the hospital, the patient falls on a wet hallway and fractures his left wrist, which is treated and casted. His daily medications for arthritis are continued while he is in the hospital. He is also given intravenous antihypertensive medications. Discharge diagnoses are hypertension, degenerative joint disease, and left wrist fracture. Which is the ICD-10-CM inpatient facility principal diagnosis?
Responses
- Hypertension
- Headache
- Nosebleed
- Fracture of the wrist
17) Patient is admitted to the acute care facility with a chief complaint of chest pain. Further examination and history determine that the patient also has joint pain, swelling of the extremities, and hair loss. Laboratory testing confirms that the patient is slightly anemic. After two days in the hospital, the patient is discharged to follow-up as an outpatient. Discharge diagnoses include myocardial infarction ruled out and possible systemic lupus erythematosus. Which is the inpatient facility principal diagnosis?
Responses
- Chest pain
- Myocardial infarction
- Anemia
- Systemic lupus erythematosus
18) A patient is admitted to the acute care facility with the chief complaint of shortness of breath. Per the patient’s history, he has been diagnosed and treated for congestive heart failure (CHF) in the past. The patient is treated during this admission with intravenous Lasix and oxygen therapy. A chest x-ray reveals minor atelectasis, which was not treated during the admission. Discharge diagnosis is CHF. Which action should the coder take regarding the documented atelectasis on the chest X-ray report?
Responses
- Do not code it because the patient did not receive treatment for it.
.
- Query the attending physician to ask if the condition should be reported.
.
- Query the radiologist to ask if the condition should be coded and reported.
.
- Assign a code for the atelectasis (along with congestive heart failure).
19) A 55-year-old male patient is admitted with chief complaints of dizziness, shortness of breath, and chest pain. The patient undergoes an electrocardiogram to determine heart functioning and serum enzymes to rule out myocardial infarction. Digoxin is administered for suspected dilated cardiomyopathy, and the patient is placed on oxygen via nasal cannula to treat both conditions. The patient also undergoes an echocardiogram and a cardiac catheterization. The echocardiogram confirms that the patient has dilated cardiomyopathy, and the cardiac catheterization confirms a myocardial infarction. After five days in the cardiac care unit, the patient is discharged to an intermediate care facility. Discharge diagnoses include myocardial infarction and dilated cardiomyopathy. For ICD-10-CM inpatient facility diagnoses, the coder should
Responses
- assign a code for the dilated cardiomyopathy only.
assign a code for the dilated cardiomyopathy only.
- assign a code for the chest pain only.
assign a code for the chest pain only.
- query the physician to ask which condition is principal.
query the physician to ask which condition is principal.
- report either dilated cardiomyopathy or myocardial infarction as principal.
20) The patient is a 54-year-old male who was a passenger in a car his son was driving. Apparently, the boy fell asleep at the wheel; the car was totaled. Patient was brought to the emergency room by ambulance. He is not sure whether he had any head trauma but complains primarily of pain in his left anterior chest and left shoulder. He was seen in the emergency room, which revealed that he had displaced fracture of his left fourth anterior rib. The physician did not see any fracture of the left shoulder but thought that there might be an acromioclavicular separation.
The patient was admitted for observation and treatment of his pain. He had tenderness over the left third and fourth anterior ribs and very little use of his left shoulder. He also had tenderness to palpation over the acromioclavicular joint. The patient was admitted and started on analgesics. He did not have much movement of his left shoulder, although this gradually improved during his hospital stay. On the second hospital day, it was noted that he had very little movement of air in the left upper lobe; repeat chest x-ray was obtained, which showed a small pleural effusion on the left and possible pneumonia in the left lower lobe. He was started on Velosef, and the chest x-ray was repeated. The pleural effusion gradually resolved, and the area of pneumonia improved. The patient was continued on the Velosef. He was subsequently discharged.
FINAL DIAGNOSES: Automobile accident. Closed fracture, left fourth anterior rib. Possible acromioclavicular joint dislocation, left. Pneumonia. Pleural effusion. (Initial encounter.)
From an ICD-10-CM inpatient facility perspective, what diagnosis(es) should/should not be reported?
Responses
- Report the rib fracture as principal.
- Do not code possible A/C dislocation.
.
- Report all listed diagnoses in the discharge diagnosis.
- Do not code rib fracture.
21) Kaposi’s sarcoma of right lung FILL IN THE BLANK
22) Acute blood loss anemia FILL IN BLANK
23) Acute narrow angle glaucoma, left eye FILL IN BLANK
24) Subarachnoid hematoma of a newborn FILL IN BLANK
25) Acute cortical kidney necrosis FILL IN BLANK
