Reference no: EM133137073

Lab: Ambulatory Diagnosis Coding.

Using the V-lab 3M Encoder, code for the primary diagnosis and CPT procedure (where possible, there may not be enough information to get a CPT code), for the following situations. (Remember, this is outpatient diagnosis coding).

Physician Office/Clinic Visits
1. Chemotherapy in oncologist's office for treatment of malignant neoplasm of lung (secondary); primary unknown.
ICD-10-CM diagnosis code(s)
CPT code:

2. Aftercare following joint replacement of right knee surgery. ICD-10-CM diagnosis code(s)
CPT code:

3. Patient is seen in the office with chief complaint of severe neck pain exacerbated by any movement. No history of injury or excessive physical activity. Physician's documentation states normal findings on physical and neurological exam. Patient instructed on immobility, heat and analgesics. No diagnosis is documented.
ICD-10-CM diagnosis code(s)
CPT code:

4. Physician sees a patient for a follow-up visit for hypertension and angina and prescribes a diuretic and nitroglycerin. The physician documents benign hypertension, angina, status post pneumonia (6 months ago), status post hysterectomy (6 years ago)
ICD-10-CM diagnosis code(s)
CPT code:

5. 4 year old boy is diagnosed with lead poisoning from eating paint off the wall in his home. ICD-10-CM diagnosis code(s)
CPT code:

6. Routine Pap Smear, including gynecological exam.
ICD-10-CM diagnosis code(s)
CPT code:

7. History: Patient has been seen frequently for hypercholesrterolemia which is uncontrolled by Cholestyramine two packets t.i.d. The patient has been placed today on Mevacor 20 mg qam. The patient also has a history of ischemic heart disease per treadmill test, however, there are some atypical features. I have placed him on 60 mg of Cardizem q.i.d. which controls his pain, however, he still has occasional chest pain lasting one to two minutes after exertion, relieved by rest. The patient has been referred to Cardiology Clinic in two weeks. He is to return to General Medicine Clinic in one month.
ICD-10-CM diagnosis code(s) CPT code:

8. Patient came in today bothered by abdominal cramps and bloating in the mornings. Symptoms have decreased from 2 years ago. Uses Combid every AM plus Metamucil every other day. No other complaints and otherwise is doing well.

P.E. Well-developed , well nourished female in no acute distress. Abdomen soft, bowel sounds active. No tenderness.
Impression: Irritable bowel syndrome (IBS) - Patient advised to add Combid at bedtime in attempt to decrease morning symptoms. Hypertension - controlled with Dyazide - will check SMA 7
ICD-10-CM diagnosis code(s) CPT code:

Emergency Room Record
1. Patient states he accidentally got a fish hook in his chin while fishing approximately 1 hour prior to evaluation. No other injuries.
Examination of chin reveals embedded fish hook in the right lateral chin area with end of hook just under the skin and easily palpable. This was forced on through the skin with cutting of barbed end with wire cutters and removal of rest of hook via the entrance wound. No significant bleeding. No evidence of any foreign body remaining. Patient was given wound care and infection precaution instructions. Started on Keflex prophylactically 250 mg. 1QID x 5 days.
Diagnosis: Foreign body, chin - removed
(hint: the fish hook, which is a foreign body, makes this complicated; think Wound) ICD-10-CM diagnosis code(s) CPT code:

Ancillary Department:
1. Patient has chronic, obstructive asthma and the attending physician sends him for a chest x-ray, (2 views) and arterial blood gas analysis.
ICD-10-CM code(s): CPT code:

2. Patient is sent for x-ray of gastrointestinal tract with KUB for lower abdominal pain, possible diverticulitis

ICD-10-CM code(s): CPT code:

Surgical Record
1. Preoperative Diagnosis: Esophageal foreign body Postoperative diagnosis: Esophageal foreign body Operation: Rigid esophagoscopy with foreign body removal
Procedure: The patient was taken to the operating room, anesthesia was induced and the patient intubated. After a satisfactory level of anesthesia, the esophageal speculum was introduced into the right piriform sinus past the cricopharyngeus and the following observations were made:
A bony structure, a fish bone, was found protruding from the right posterior esophageal wall. This was grasped and removed from the esophageal wall through the esophageal speculum. On examination of the esophagus, there appeared to be a small, pinpoint area where the bone had embedded itself in the esophageal wall with no significant edema. The distal esophagus was evaluated with a 6 x 30 esophagoscope and there appeared to be no fragments nor perforations. The patient was then awakened from anesthesia and taken to the recovery room in good condition.
ICD-10-CM diagnosis code(s): CPT code:

2. Preoperative Diagnosis: Sustained elevated intraocular pressure Postoperative Diagnosis: Reduced intraocular pressure Operation: Anterior chamber paracentesis
Procedure: The patient ws prepped with Betadine swabs over the surface of the skin of the right eye. Sterile lid speculums were placed into the eye after instillation of sterile topical anesthesia. The patient's Gentamicin solution was used two minutes times three. A tooth forceps was used to grasp the limbus at 8:30 o'clock and a 30 gauge needle on a tuberculin syringe with plunger removed was introduced into the anterior chamber over the plan of the iris. Then .1 cc of fluid was removed from the eye and postoperative pressure was 38.
There were no intraoperative complications.
ICD-10-CM diagnosis code(s): CPT code:

3. Preoperative Diagnosis: End-stage renal disease, secondary to diabetes nephropathy Postoperative Diagnosis: Same
Operation: Acute hemodialysis

This procedure was done with the patient lying down in bed. Cardiac monitor was in place. Dialyzer HF 140, dialysate 830 consistent with 3 K bath glucose and acetate. Bicarbonate drip used throughout the procedure 8.4% at 50 cc per hour. Procedure was done for four hours. AV graft was used as the access. Blood flow was 200 ml per minute tolerated. Negative pressure initiated at minus 25, and graduated to minus 200. Hemodynamically the patient remained fairly stable, and pre-dialysis blood pressure was 110/90, and post-dialysis blood pressure was 150/60. Patient will be observed closely and will be dialysed again as necessary.
ICD-10-CM code(s): CPT code:

4. Preoperative Diagnosis: Cervical dysplasia Postoperative Diagnosis: Cervical dysplasia Operation: Laser ablation of the cervix
Procedure: The patient was taken to the operating room and placed in the supine position. IV anesthesia was then given and the patient was then placed in the lithotomy position. A speculum was placed inside the cervix and colposcopy was performed using 1% acetic acid. Then the abnormal areas of the cervix were identified that are as outlined with laser and the remaining portion of the cervix filled in with the laser. After a depth of 5 to 6 mm was reached the procedure was stopped. Hemostatsis was adequate. The speculum was removed and the patient ws returned to hte supine position and she was taken to the recovery room in stable condition. There were no complications. There were no specimens.
ICD-10-CM code(s): CPT code:

5. Preoperative Diagnosis: Mucous retention cyst of tongue Postoperative Diagnosis: same
Operation: Excisional biopsy of tongue lesion
Procedure: the patient was taken to the minor operating room and placed in the supine position. The tongue was protruded and on the anterior and lateral surface was a 1 x .5 cm lesion. The area was then anesthetized with Lidocaine with 1: 100,000 epinephrine in a field block. A fusiform incision was then used to excise the lesion without difficult. The wound was then closed with three interrupted 3-0 chromic sutures. The patient tolerated the procedure well. The estimated blood loss was approximately 5 cc. All sponges were accounted for. The duration of the procedure was five minutes.
ICD-10-CM code(s): CPT code:

Attachment:- Ambulatory Diagnosis Coding.rar