Using the techniques described in this chapter carefullyread through the case study and determine the most accurateICD-10-CM code(s) and external cause code(s) if appropriate.Remember, check the chapter specific, sub-chapter specific andcategory specific notations within the Tabular list.
WESTON EYE CENTER
658 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-7892
PATIENT: OLDENBERG, KYLE
ACCOUNT/EHR #: OLDEKY001
DATE: 10/17/18
Attending Physician: Renee O. Bracker, MD
Kyle Oldenberg, 65-year-old male, presents today with thecomplaints of gradual loss of vision OD of a 2-month duration. Kylestates it doesn’t hurt, “just getting to where I can’t see.” Kylesaw his ophthalmologist and was diagnosed with angle closureglaucoma and was referred to us for treatment.
PMH: Healthy, no medications
FH: Noncontributory with no history ofglaucoma
SH: Drinks alcohol socially and denies use oftobacco.
Eye Exam:
- Best corrected visual acuities: 20/20 OS, barely hand motionvision OD.
- Pupils: >2.9 LU RAPD OD
- EOM: full OU
- IOP: 17 mmHg OS, 66 mmHg OD
- DFE: retina exam—normal macula, vessels, and periphery OU.Optic nerves: 0.3 C/D OS, complete cup OD.
Gonioscopy: moderately open angles OD. (+)Sampaolesi’s line OD.
Dx: Pseudoexfoliation glaucoma, moderatestage
P: Selective laser trabeculoplasty (ALT orSLT).
ROB/pw D: 10/17/18 09:50:16 T: 10/19/18 12:55:01
Be sure to list the codes, one code per box, in the correctorder, from top to bottom. Capitalization, punctuation, and spacingcan impact whether or not your answer is correct. Follow codingbest practices.
What is/are the correct diagnosis code(s)?
