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Apr 3, 2024

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5. INPATIENT HOSPITAL Gender: F Age: 17 Preprocedure diagnosis: second debridement for extensive burns on both arms Procedure: excisional debridement and graft. Cut out necrotic subcutaneous tissue and fascia and applied autologous skin substitute on both lower arms and nonautologous tissue substitute on both upper arms. ICD-10-PCS Code 1 0JRD0KZ 5. INPATIENT HOSPITAL Gender: F Age: 17 ICD-10-PCS Code 2 5. INPATIENT HOSPITAL Gender: F Age: 17 ICD-10-PCS Code 3 5. INPATIENT HOSPITAL Gender: F Age: 17 ICD-10-PCS Code 4 This 82-year-old female was admitted for acute exacerbation of chronic obstructive pulmonary disease. The progress notes indicate that the patient received a transfusion for anemia. The discharge diagnoses state acute exacerbation of chronic obstructive pulmonary disease and pancytopenia. Transfusion of nonautologous packed red blood cells was given via peripheral vein. What codes are assigned for this case? Principal diagnosis code in ICD-10: Additional Diagnoses code in ICD-10: Procedure code in ICD-10: An 80-year-old patient with hypertension was admitted to the hospital for cholecystectomy. The patient underwent an attempted laparoscopic cholecystectomy, but due to extensive adhesions, it had to be converted to an open cholecystectomy with exploration of the common duct and choledocholithotomy. Final diagnostic statement: 1. Acute and chronic cholecystitis with choledocholithiasis and cholelithiasis. 2. Hypertension. Principal diagnosis code in ICD-10: K80.66 . Review ICD-10-PCS Coding Guideline B3.11c. regarding coding Inspection procedures.

Additional diagnoses code 1 in ICD-10: I10 Additional diagnoses code 2 in ICD-10: Z53.09 Additional diagnoses code 3 in ICD-10: For code 0FT40ZZ, the Alphabetic Index main term is Resection, subterm gallbladder. Additional Procedure code 1 in ICD-10: For code 0FC90ZZ, the Alphabetic Index main term is Choledocholithotomy Additional Procedure code 2 in ICD-10: For code 0FJ44ZZ, the Alphabetic Index main term is Inspection, subterm gallbladder. 8. INPATIENT HOSPITAL Gender: F Age: 32 Diagnosis: traumatic brain injury, cervical musculoskeletal strain Procedure: neuromuscular reeducation including therapeutic conditioning exercise to improve range of motion, strength, and coordination; home management Plan: patient did not reach goal because he has been admitted to inpatient rehabilitation ICD-10-PCS Code 1 F07M6GZ ICD-10-PCS Code 2 F08Z4ZZ ICD-10-PCS Code 2 F08Z4ZZ 9. INPATIENT HOSPITAL Gender: M Age: 59 Diagnosis: atrial fibrillation, persistent, with rapid ventricular rate Procedure: transesophageal echocardiogram (TEE) and direct current cardioversion. Transesophageal probe was placed in the esophagus, and views of the right and left heart were then obtained. Following this, direct current cardioversion performed. Unsuccessful conversion to sinus rhythm; remained in atrial fibrillation.

ICD-10-PCS Code 1 B246ZZ4 ICD-10-PCS Code 2 5A2204Z ICD-10-PCS Code 2 5A2204Z The patient, a 29-year-old woman, was admitted due to numbness in the right arm. Based on the physical exam and the presence of saline breast implants, the physician ordered ultrasound and MRI exams of both breasts. The results showed her bilateral breast implants were leaking, causing thoracic outlet syndrome. She underwent surgery to remove both implants and chose not to have them replaced at this time. Assign diagnosis codes for the conditions. Assign procedure codes for the imaging studies and removal of the implants (open procedure). Dx: Leaking breast implants Procedures: Bilateral breast ultrasound and bilateral breasts—MRI—with and without contrast; removal of saline breast implants Principal diagnosis in ICD-10: Leaking breast implants—T85.43XA; ; ; Bilateral breast US—BH42ZZZ; bilateral MRI of breasts, with and without contrast—BH32Y0Z Additional diagnoses in ICD-10: G54.0 Thoracic outlet syndrome—G54.0 (brachial plexus disorders) Principal procedure code 1 in ICD-10: 0HPT0JZ Bilateral removal of breast implants—0HPT0JZ, 0HPU0JZ Principal procedure code 2 in ICD-10: 0HPU0JZ Bilateral breast US—BH42ZZZ Additional procedure code 1 in ICD-10: BH42ZZZ Additional procedure code 2 in ICD-10: BH32Y0Z

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7. INPATIENT HOSPITAL Gender: F Age: 29 Preprocedure diagnosis: two second-trimester miscarriages, high risk for premature birth, cervical incompetence at 12 weeks Procedure: transvaginal intraluminal cervical cerclage using the Shirodkar technique. The cervix was exposed at the level of the internal os and a curved Allis clamp was used to grasp the lateral edges of the anterior and posterior aspects of the transverse incisions and some paracervical tissue. A suture was then placed anteriorly and tied posteriorly using a 5-mm tape suture with a double blunt needle at each end. (Restriction, cervix; Table: via natural or artificial opening (transvaginal), no device, no qualifier) 6. OUTPATIENT SURGERY Gender: M Age: 17 Preprocedure diagnosis: hyperhidrosis involving the soles of the feet, hands, and underarms Procedure: bilateral endoscopic thoracic sympathectomy Postprocedure diagnosis: hyperhidrosis involving the soles of the feet, hands, and underarms (Excision, nerve, thoracic sympathetic, Table: percutaneous endoscopic, no device, no qualifier) Additional diagnoses code 1 in ICD-10: Driver of car that hit tree—V47.02XA Additional diagnoses code 2 in ICD-10: HTN—I10 Additional diagnoses code 3 in ICD-10: GERD—K21.9 Additional diagnoses code 4 in ICD-10: Glaucoma—H40.9 Principal procedure code in ICD-10: Immobilization of neck—2W32X3Z A patient was involved in an auto accident. He was the driver of a car that hit a pothole, and he lost control of the car and hit a tree. The airbags deployed. He arrives at the ED on a backboard and has a cervical collar around his neck. He is complaining of neck pain with radiation down the right arm. His past medical history

is significant for HTN, GERD, glaucoma, and right knee replacement. His blood pressure was slightly elevated on arrival at the ED and was closely monitored. Based on his physical symptoms, he had a CT of the head and neck, which were negative for bony injury. After the patient was admitted for monitoring, the physician decided to seek an ophthalmic consult because he wanted to make sure there was no injury to his eyes. Aside from the pre-existing glaucoma, the eyes appeared to be uninjured. He was placed in a neck brace, discharged with some muscle relaxants, and told to follow up with his PCP. Diagnoses: whiplash injury, cervical spine; HTN, GERD, glaucoma Principal diagnosis in ICD-10: Whiplash injury—S13.4XXA;; Additional procedure code 1 in ICD-10: CT head and neck—BW29ZZZ Additional procedure code 3 in ICD-10: Eye exam—08J1XZZ, Left? Additional procedure code 2 in ICD-10: Eye exam—08J0XZZ, Right? 7.12. The patient is a 56-year-old male who was admitted with a history of hematemesis for the past 36 hours. He also had some tarry black stools and was noted to have a giant gastric ulcer which was actively bleeding. Patient was subsequently referred for surgical intervention. Procedure Performed: Subtotal gastrectomy with Billroth II anastomosis The root operation for the anastomosis is Bypass, which is defined as altering the route of passage of the contents of a tubular body part. The fourth character of a bypass procedure indicates bypassed from (in this case the stomach) and the seventh character indicates bypass to (in this case the jejunum). 7.12. Additional procedure code 1 in ICD-10: The root operation for the anastomosis is Bypass, which is defined as altering the route of passage of the contents of a tubular body part. The fourth character of a bypass procedure indicates bypassed from (in this case the stomach) and the seventh character indicates bypass to (in this case the jejunum). 7.12. Additional procedure code 2 in ICD-10: The root operation for the anastomosis is Bypass, which is defined as altering the route of passage of the contents of a tubular body part. The fourth character of a bypass procedure indicates bypassed from (in this case the stomach) and the seventh character indicates bypass to (in this case the jejunum).

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