PLEASE HELP ME WITH MEDICAL CODING CODES homework
1. Office Gender: Female Age: 32 a. Chief Complaint: managementof multiple myeloma b. Assessment: multiple myeloma c. Plan:recheck in 6 months Please assign the correct ICD 10 CM Code(s) forthis clinical case
2)Office Gender: Female Age: 63 1 Chief Complaint: monitoring ofbenign neoplasm 2 Assessment: benign islet cell neoplasm of thepancreas 3 Plan: return visit if any new problems arise Pleaseassign the correct ICD 10 CM Code(s) to this clinical case
3)Outpatient Hospital Gender: Female Age: 66 4 Chief Complaint:screening colonscopy 5 Assessment: personal history of carcinoma ofthe colon which was successfully removed five years ago, no newfindings today 6 Plan: colonoscopy in 5 years Please assign thecorrect ICD 10 CM Code(s) to this clinical case
4)Inpatient Hospital Gender: Female Age: 81 7 Reason foradmission: admitted from Emergency Department after collapsing athome, arrive by ambulance 8 Assessment: dehydration andhyponatremia (sodium deficiency) due to chemotherapy for metastaticbilateral ovarian cancer Please assign the correct to ICD-10-CMcode (s) for the clinical cases
QUESTION 5 INPATIENT HOSPITAL GENDER: MALE AGE: 27 A. REASON FORADMISSION: LUMBAR PAIN, WEAKNESS IN THE LEFT LEG B. DISCHARGEDIAGNOSIS: PROBABLE HERNIATED INTERVERTEBRAL DISC, SCIATICA C.PLAN: REFER TO PHYSICAL THERAPY PLEASE ASSIGN THE CORRECT TOICD-10-CM CODE (S) FOR THE CLINICAL CASES
QUESTION 6 Office Gender: Female Age: 41 a. Reason for visit:review abnormal mammogram results b. Assessment:microcalcifications in right breast c. Plan: mammogram withmagnification to rule out cancer Please assign the correct toICD-10-CM code (s) for the clinical cases
7) OFFICE GENDER: FEMALE AGE: 36 A. REASON FOR VISIT: DAILYHEADACHES B. ASSESSMENT: LIKELY MIGRAINES C. PLAN: REFER TONEUROLOGIST FOR FURTHER TESTING AND EVALUATION PLEASE ASSIGN THECORRECT TO ICD-10-CM CODE (S) FOR THE CLINICAL CASES
8)Office Gender: Female Age: 31 9 Reason for visit: review lungX Ray 10 Assessment: abnormal shadow, right lung, inferior lobe 11Plan: refer to pulmonologists Please assign the correct toICD-10-CM code (s) for the clinical cases
9)Inpatient Gender: Female Age: 30 12 Reason for visit: LUQpaint and swelling increasing over the past 3 days, indigestion 13Assessment: IV fluids, pain control, nasogastric suctioning 14Discharge diagnosis: acute pancreatitis due to opioid dependenceand intoxication Please assign the correct to ICD-10-CM code (s)for the clinical cases
10)Emergency Department Gender: Male Age: 12 15 Chief Complaint:”My son forgot that he is not supposed to eat eggs and ate ahardboiled egg at his friend’s house.” He has diarrhea and vomitingfor 4 hours 16 Assessment: allergic gastroenteritis due to eggs 17Plan: Rx antiemetic, antidiarrheal Please assign the correct ICD 10CM Code(s) for this clinical case
11)Inpatient Hospital Gender: Female Age: 41 18 Reason foradmission: admitted from ED with severe and steady abdominal pain,fever, excessive perspiration, T 101 19 Treatment: IV antibiotics,fluids, colectomy 20 Discharge diagnosis: generalized peritonitisdue to E. Coli, irritable bowel syndrome Please assign the correctICD 10 CM Code(s) for this clinical case
12)Office Gender: Male Age: 36 21 Chief Complaint: “I’ve beenhaving problems with my GERD” 22 Assessment: GERD 23 Plan: adjustRx, call if problems continue recheck in 6 months Please assign thecorrect ICD 10 CM Code(s) for this clinical case
13)Inpatient Hospital Gender: Female Age: 35 24 Reason foradmission: T 102 F, tachycardia, extreme anxiety, nausea, diarrhea25 Assessment: thyrotoxicosis with goiter and thyroid storm 26Plan: RX PTU (propylthiouracil) for thyroid and beta blockerpropranolol to control heart rate Please assign the correct ICD 10CM Code(s) for this clinical case
14)Inpatient Hospital Gender: Male Age: 42 27 Reason foradmission: Patient found non-responsive. Family reports patientbeing on a fast 28 Assessment: nondiabetic hypoglycemic coma 29Plan: instructed on diet and glucometer, FU 1 week Please assignthe correct ICD 10 CM Code(s) for this clinical case
15)Office Gender: Female Age: 25 30 Chief compliant: weightloss, decreased appetite, decreased sexual drive, and increasedsensitivity to cold 31 Assessment: hypopituitarism 32 Plan: hormonereplacement therapy, FU 4 wk Please assign the correct ICD 10 CMCode(s) for this clinical case
16)Office Gender: Female Age: 51 33 Reason for encounter: Annualcheck-up 34 Assessment: Test results show abnormally low vitamin Dlevel. Patient is obese due to excess calories and has a BMI of30.5 35 Plan: Rx vitamin D 50,000 IU/week for 8 weeks, then recheckPlease assign the correct ICD 10 CM Code(s) for this clinicalcase
17)Office Gender: Male Age: 48 36 Chief Compliant: insomnia,hand tremor, hyperactivity, excessive sweating, weight loss 37Assessment: Graves’ disease with uninodular goiter 38 Plan:radioiodine therapy Please assign the correct ICD 10 CM Code(s) forthis clinical case
18)Office Gender: Female Age: 24 39 Reason for encounter:painful blisters on the skin and mucous membrane of the mouth 40Assessment: pemphigus vulgaris 41 Plan: Rx steroids, FU PCP 2 wkPlease assign the correct ICD 10 CM Code(s) for this clinicalcase
19)Office Gender: Male Age: 89 42 Reason for encounter: Red openskin area in sacral region 43 Assessment: pressure ulcer, stage 3,sacral region 44 Plan: Debrided wound and applied dressing, Referto wound care clinic for FU Please assign the correct ICD 10 CMCode(s) for this clinical case
20)Inpatient Hospital Gender: Female Age: 3 45 Reason foradmission: body covered with blisters, child appears to be in pain46 Assessment: Ritter’s disease, involving 68% of body surface 47Plan: Rx pain medication, return to burn center for skindebridement Please assign the correct ICD 10 CM Code(s) for thisclinical case
21)Outpatient Surgery Gender: Male Age: 44 48 Reason forencounter: repair of scar 49 Assessment: keloid scar 50 Plan:repaired scar, monitor infection Please assign the correct ICD 10CM Code(s) for this clinical case
22)Inpatient Hospital Gender: Male Age: 45 51 Reason foradmission: sudden onset of pain and swelling in left hip, fever 52Testing: arthrocentesis, blood culture, X-ray, 53 Assessment:bacterial pyogenic arthritis due to Pseudomonas aeruginosa, likelydue to patient’s intravenous drug abuse Please assign the correctICD 10 CM Code(s) for this clinical case
23)Office Gender: Female Age: 61 54 Reason for encounter: pain,redness, and swelling in left knee 55 Assessment: abscess of bursa,left knee, due to Streptococcus A 56 Plan: Reapply dressing asdirected. Take antibiotic as instructed Please assign the correctICD 10 CM Code(s) for this clinical case
24)Office Gender: Female Age: 15 57 Reason for encounter:Swollen glands and high fever with pain in right shoulder, rightelbow, right hand, Abdominal spasmodic pain and diarrhea 58Assessment: juvenile arthritis with system onset (Still disease),shoulder , elbow, hand and ulcerative colitis 59 Plan: Rxanti-inflammatory, RTO 3 week Please assign the correct ICD 10 CMCode(s) for this clinical case 25)Office Gender: Male Age: 47 60Reason for encounter: weakness in the right foot forefoot 61Assessment: drop foot 62 Plan: Refer to PT for fitting oflightweight orthoses Please assign the correct ICD 10 CM Code(s)for this clinical case
26)Office Gender: Male Age: 48 63 Reason for admission: Admittedfrom emergency department, where he was seen after an accidentwhile riding as a passenger in an off-road recreational vehicle 64Assessment: transverse fracture right tibia shaft, notifiedpatient’s oncologist, who is currently treating him for prostatecancer 65 Plan: FU with oncologist and orthropedic surgeon inoffice Please assign the correct ICD 10 CM Code(s) for thisclinical case
27) Inpatient Hospital Gender: Male Age: 45 66 Reason foradmission: Admitted from emergency dues to skull fracture. He wasunconscious for 90 minutes, but returned to his normal state ofconsciousness 67 Assessment: open occipital condylar fracture (TypeI) of base of skull with subarachnoid hemorrhage 68 Plan:Craniotomy performed based on CT results which showed bleeding.Vessel occlusion performed. Patient in ICU following surgery. RTO 4days post discharge and weekly thereafter for two weeks Pleaseassign the correct ICD 10 CM Code(s) for this clinical case
28)Inpatient Hospital Gender: Female Age: 71 69 Chief Complaint:swollen and painful right wrist and large bruises on right calfafter she tripped and fell in the living room of her apartmentyesterday 70 Assessment: Colles fracture. Extensive hematoma on thecalf is due to her term Coumadin therapy. Patient was previouslydiagnosed with age-related osteoporosis. 71 Plan: Arm casted, INRperformed, RTO to access healing of fracture and cast removalPlease assign the correct ICD 10 CM Code(s) for this clinicalcase
29)Inpatient Hospital Gender: Male Age: 91 72 Reason foradmission: arrived by ambulance to emergency department for severeabdominal pain 73 Assessment: ruptured abdominal aortic aneurysm 74Discharge status: deceased Please assign the correct ICD 10 CMCode(s) for this clinical case
30)Inpatient Hospital Gender: Male Age: 71 75 Reason foradmission: admitted from emergency department for inferolateralSTEMI 76 Assessment: On the third day after admission, patient hada second STEMI in the same location 77 Plan: CABG x 3 Please assignthe correct ICD 10 CM Code(s) for this clinical case
31)Inpatient Hospital Gender: Male Age: 82 a. Reason foradmission: left sided paralysis, inability to walk, inability toformulate words b. Assessment: cerebral infarction due to embolismin right common carotid artery with pharyngeal dysphagia andleft-non dominant hemiplegia c. Plan: Rehab for mobility andspeech, medication to address blood pressure issues, FU withprimary care physician Please assign the correct ICD 10 CM Code(s)for this clinical case
32)Inpatient Hospital Gender: Female Age: 45 a. Reason foradmission: bone marrow transplant b. Assessment: secondarymyelofibrosis due to right breast cancer c. Plan: not availablePlease assign the correct ICD 10 CM Code(s) for this clinical case33) Office Gender: Female Age: 12 a. Reason for encountermanagement and monitoring of thrombophilia b. Assessment:congenital antithrombin III deficiency c. Plan: INR protocol,anticoagulation medication Please assign the correct ICD 10 CMCode(s) for this clinical case
34)Inpatient Hospital Gender: Female Age: 28 a. Reason foradmission: Palpitations, rapid heartbeat, long bone pain, enlarged,painful spleen. Admit patient for transfusion, IV therapy, painmanagement, and splenectomy b. Assessment: Sickle Cell Crisis withsplenic squestration c. Plan: RTO in one week for CBC and postoperative check Please assign the correct ICD 10 CM Code(s) forthis clinical case
35) Inpatient Hospital Gender: Male Age: 36 a. Reason foradmission: difficulty breathing b. Assessment: spontaneouspneumothorax secondary to a ruptured bulla c. Plan: X-Ray confirmedreexpansion of lung, pulmonary clinic FU 1 week Please assign thecorrect ICD 10 CM Code(s) for this clinical case 1) Office Gender:Male Age: 5 a. Reason for encounter: referred by pediatrician fordysphagia b. Assessment: congenital esophageal web with esophagealspasm and reflux espohagitis c. Plan: schedule ballon dilation andelectrocauterization Please assign the correct ICD 10 CM Code(s)for this clinical case
2) Office Gender: Female Age: 34 Gravida 2 Para 2 Date ofDelivery:3/15/YY a. Reason for encounter: postpartum care b.Assessment: abscess of right breast c. Plan: Rx antibiotic, RTO 2weeks 3) Please assign the correct ICD 10 CM Code(s) for thisclinical case
3) Inpatient Hospital Gender: Male Age: 60 a. Reason foradmission: acute respiratory distress b. Assessment: myastheniagravis crisis, chronic inflammatory demyelinating polyneuropathy c.Plan: Rx cholinesterase inhibitor and immunosupressant drugs, FU 1week Please assign the correct ICD 10 CM Code(s) for this clinicalcase
4) Office Gender: Male Age: 55 b. Reason for admission: sleepstudy c. Assessment: obstructive sleep apnea, nutritional obesitywith BMI 33.0 d. Plan: RX continuous positive airway pressure(CPAP) device, refer to dietician for weight loss Please assign thecorrect ICD 10 CM Code(s) for this clinical case.
