Using the techniques described in this chapter carefully read through the case study and determine the most accurate ICD-10-CM code(s) and external cause code(s) if appropriate. Answer each question as it guides you through the coding process. Remember; check the chapter specific, sub-chapter specific and category specific notations within the Tabular list. William Amerson, a 41-year-old male, comes in for his annual eye examination. Dr. Leviner notes a benign right conjunctiva nevus. Be sure to list the codes, one code per box, in the correct sequence. Capitalization, punctuation, and spacing can impact whether or not your answer is correct. Follow coding best practices. Principle diagnosis: Where should you begin to look up the code in the coding manual? (Click to select) External cause of injuries index Index to Diseases and Injuries Table of Neoplasms Table of Drugs and Chemicals Tabular List of Diseases and Injuries What is the key term? (Click to select) External cause of injuries index Examination Conjunctiva Eye Nevus Do any of the following apply to the condition? (Click to select) Malignant, primary With abnormal findings Ca in situ Normal findings Begin to code the encounter. Did you verify the code in the Tabular List of Diseases and Injuries? (Click to select) Yes No Is there an Includes notation? (Click to select) Yes No If so does the Includes note help to clarify? (Click to select) Yes No No Includes note Is there a Code first notation? (Click to select) Yes No If so does the Code first note apply to the case study? (Click to select) Yes No No Code first note Is there a Code also notation? (Click to select) Yes No If so does the Code also note apply to the case study? (Click to select) Yes No No Code also note Is there a Use additional code notation? (Click to select) Yes No If so does the Use additional code note apply to the case study? (Click to select) Yes No No Use additional code note

Is there an Excludes1 notation? (Click to select) Yes No If so does the Excludes1 note apply to the case study? (Click to select) Yes No No Excludes1 note Is there an Excludes2 notation? (Click to select) Yes No If so does the Excludes2 note apply to the case study? (Click to select) Yes No No Excludes2 note Is there a symbol indicating additional characters are required? (Click to select) Yes No Do you need to use the placeholder “X”? (Click to select) Yes No Did you code to the highest level of specificity? (Click to select) Yes No What is the correct diagnosis code? Secondary diagnosis: Where should you begin to look up the code in the coding manual? (Click to select) External cause of injuries index Index to Diseases and Injuries Table of Neoplasms Table of Drugs and Chemicals Tabular List of Diseases and Injuries What is the key term? (Click to select) Examination Conjunctiva Eye Nevus What is the anatomical site? (Click to select) Blue Capillary Cavernous Conjunctiva What is the laterality? (Click to select) Right Left Bilateral Unspecified Do any of the following apply to the condition? (Click to select) Malignant, primary Malignant, secondary Ca in situ Benign Do any of the following apply to the condition? (Click to select) Acute Chronic Recurrent None of these Begin to code the encounter. Did you verify the code in the Tabular List of Diseases and Injuries? (Click to select) Yes No Is there an Includes notation? (Click to select) Yes No If so does the Includes note help to clarify? (Click to select) Yes No No Includes note Is there a Code first notation? (Click to select) Yes No If so does the Code first note apply to the case study? (Click to select) Yes No No Code first note Is there a Code also notation? (Click to select) Yes No