quiz-7-assignment icd

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University of the District of Columbia *

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270

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Health Science

Date

Dec 6, 2023

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docx

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175

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lOMoARcPSD
lOMoARcPSD|30654871 QUIZ 7 George McKeown, a 65-year-old male, presents with pain around his right eye and sensitivity to bright light. Dr. Zabawa notes redness of the eye and sagging skin around the lower eyelid. George is diagnosed with entropion of the right eye, lower eyelid……H02.002 Principal diagnosis: Where should you begin to look up the code in the coding manual – Index to Diseases and Injuries What is the key term – Entropion What is the anatomical site – Eye What is the laterality – Right Do any of the following apply to the condition – Lower eyelid Do any of the following apply to the condition – Unspecified Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - No If so does the Includes note help to clarify – No Includes notation Is there a Code first notation - No If so does the Code first note apply to the case study – No Code first notation Is there a Code also notation – No If so does the Code also note apply to the case study – No Code also notation Is there a Use additional code notation – No If so does the Use additional code note apply to the case study – No Use additional code notation Is there an Excludes1 notation – Yes If so does the Excludes1 note apply to the case study – No Is there an Excludes2 notation - Yes If so does the Excludes2 note apply to the case study – No Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – H02.002 Overall Feedback: H02.002: Entropion>right>lower Rosa Fuller, a 24-year-old female, presents with ear pain. Dr. Rider documents a thick greyish-white matter. After a thorough examination, Rosa is diagnosed with diffuse otomycosis, external ear. Principal diagnosis: Where should you begin to look up the code in the coding manual – Index to Diseases and Injuries What is the key term – Otomycosis What is the location – external Do any of the following apply to the condition – None of these Is there a manifestation code - Yes Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - Yes If so does the Includes note help to clarify – Yes Is there a Code first notation - No If so does the Code first note apply to the case study – No Code first notation Is there a Code also notation – No If so does the Code also note apply to the case study – No Code also notation Is there a Use additional code notation – Yes If so does the Use additional code note apply to the case study – No Is there an Excludes1 notation – Yes If so does the Excludes1 note apply to the case study – No Is there an Excludes2 notation - Yes If so does the Excludes2 note apply to the case study – No Downloaded by LaShawn Forrest (lalaforrest0304@outlook.com)
lOMoARcPSD|30654871 Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – B36.9 What is the manifestation code – H62.40 Second diagnosis: Where should you begin to look up the code in the coding manual – Index to Diseases and Injuries What is the key term – Otitis What is the location – Externa In – Mycosis NEC Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - No If so does the Includes note help to clarify – No Includes notation Is there a Code first notation - Yes If so does the Code first note apply to the case study – Yes Is there a Code also notation – No If so does the Code also note apply to the case study – No Code also notation Is there a Use additional code notation – No If so does the Use additional code note apply to the case study – No Use additional code notation Is there an Excludes1 notation – Yes If so does the Excludes1 note apply to the case study – No Is there an Excludes2 notation - Yes If so does the Excludes2 note apply to the case study – No Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – H62.40 Overall Feedback: B36.9: Otomycosis H62.40: Otitis>externa>in>mycosis NEC John Di Toma, a 10-month-old male, was diagnosed with congenital bilateral cataracts several weeks ago. John is admitted today for the surgical removal of the cataracts. Principal diagnosis: Where should you begin to look up the code in the coding manual – Index to Diseases and Injuries What is the key term – Cataract Do any of the following apply to the condition – Congential Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - No If so does the Includes note help to clarify – No Includes notation Is there a Code first notation - No If so does the Code first note apply to the case study – No Code first notation Is there a Code also notation – No If so does the Code also note apply to the case study – No Code also notation Is there a Use additional code notation – No If so does the Use additional code note apply to the case study – No Use additional code notation Is there an Excludes1 notation – No If so does the Excludes1 note apply to the case study – No Is there an Excludes2 notation - Yes If so does the Excludes2 note apply to the case study – No Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – Q12.0 Downloaded by LaShawn Forrest (lalaforrest0304@outlook.com)
lOMoARcPSD|30654871 Overall Feedback: Q12.0: index>cataract>congenital Latoya Simpkins, a 36-year-old female, presents with the complaint of right ear pain. Dr. Herauf also documents a low-grade fever, cough, and nasal drainage. Dr. Herauf completes an examination with otoscope, which visualizes a cloudy bulging eardrum with blisters. Latoya is diagnosed with bullous myringitis. Principal diagnosis: Where should you begin to look up the code in the coding manual – Index to Diseases and Injuries What is the key term – Myringitis Do any of the following apply to the condition – Acute What type – Bullous What is the laterality - Right Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - No If so does the Includes note help to clarify – No Includes notation Is there a Code first notation - No If so does the Code first note apply to the case study – No Code first notation Is there a Code also notation – No If so does the Code also note apply to the case study – No Code also notation Is there a Use additional code notation – No If so does the Use additional code note apply to the case study – No Use additional code notation Is there an Excludes1 notation – Yes If so does the Excludes1 note apply to the case study – No Is there an Excludes2 notation - Yes If so does the Excludes2 note apply to the case study – No Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – H73.011 Overall Feedback: H73.011: Myringitis>acute>bullous>right 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 the complaints of gradual loss of vision OD of a 2-month duration. Kyle states it doesn’t hurt, “just getting to where I can’t see.” Kyle saw his ophthalmologist and was diagnosed with angle closure glaucoma and was referred to us for treatment. PMH: Healthy, no medications FH: Noncontributory with no history of glaucoma SH: Drinks alcohol socially and denies use of tobacco. Eye Exam: • Best corrected visual acuities: 20/20 OS, barely hand motion vision OD. • Pupils: >2.9 LU RAPD OD • EOM: full OU • IOP: 17 mmHg OS, 66 mmHg OD Downloaded by LaShawn Forrest (lalaforrest0304@outlook.com)
lOMoARcPSD|30654871 • 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, moderate stage P: Selective laser trabeculoplasty (ALT or SLT). ROB/pw D: 10/17/18 09:50:16 T: 10/19/18 12:55:01 Principal diagnosis: Where should you begin to look up the code in the coding manual – Index to Diseases and Injuries What is the key term – Glaucoma What type – Open angle Do any of the following apply to the condition - Primary Do any of the following apply to the condition – Capsular What it the laterality – Right What stage - Moderate Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - No Is there a Code first notation - No Is there a Code also notation – No Is there a Use additional code notation – No Is there an Excludes1 notation – Yes Is there an Excludes2 notation - Yes Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – H40.1412 Overall Feedback: H40.1412: Glaucoma>open angle>primary>capsular>right>moderate stage PATIENT: SEQUEN, EUGENE ACCOUNT/EHR #: SEQUEU001 DATE: 09/16/18 Attending Physician: Oscar R. Prader, MD Patient is a 49-year-old male diagnosed with chronic acid reflux. Barium swallow fluoroscopy, esophageal pH probe, esophageal manometry, and esophagoscopy were completed. He presents today to discuss the results of those tests. I explain that the test results indicate that he has GERD. The first course of treatment is to adopt a lowfat, high-fiber diet. The second course would be surgical repair. Patient was instructed not to eat at least 2 hours before going to bed, and the head of the bed should be elevated 6 to 8 inches while in supine position. Patient was informed that surgery may be necessary if diet and positioning do not relieve symptoms. Principal diagnosis: Where should you begin to look up the code in the coding manual – Index to Diseases and Injuries What is the key term – Reflux What type – Gastroesophageal Downloaded by LaShawn Forrest (lalaforrest0304@outlook.com)
lOMoARcPSD|30654871 Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - No Is there a Code first notation - No Is there a Code also notation – No Is there a Use additional code notation – No Is there an Excludes1 notation – Yes Is there an Excludes2 notation - Yes Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – K21.9 Overall Feedback: K21.9: Reflux>gastroesophageal PATIENT: BARDARO, LYNNE ACCOUNT/EHR #: BARDLY001 DATE: 10/16/18 Attending Physician: Renee O. Bracker, MD S: Lynne, a 37-year-old female, presents today with the complaint that her right ear is throbbing. O: T: 101, BP: 137/83, R: 21, P: 78. PERRLA. Lynne is in moderate discomfort. She admits to a pain level of 4 on a scale of 0–10. Past medical history: noncontributory. Review of systems: negative. Medications: none. Ear exam: Left is within normal range. Right pinna: a lump is noted, as well as swelling and inflammation. It appears to be a localized pool of blood. Dr. Bracker evacuates the blood and applies a pressure bandage. A: Auricle hematoma P: Rx: antibiotics Follow up with patient in 10–14 days. Principal diagnosis: Where should you begin to look up the code in the coding manual – Index to Diseases and Injuries What is the key term – Disorder What is the anatomical site – Pinna Do any of the following apply to the condition - Hematoma What is the laterality - Right Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - No Is there a Code first notation - No Is there a Code also notation – No Is there a Use additional code notation – No Is there an Excludes1 notation – No Is there an Excludes2 notation - Yes Is there a symbol indicating additional characters are required - Yes Downloaded by LaShawn Forrest (lalaforrest0304@outlook.com)
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