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Instructions: Review each case study and select the correct ICD-10-CM diagnostic code. Please be aware that...

Instructions: Review each case study and select the correct ICD-10-CM diagnostic code. Please be aware that when an answer consists of more than one code, there will be an answer blank for each code.
Case 1
Physician Office Visit
This 39-year-old female recently underwent GYN surgery and now is experiencing sleeplessness, headache, and lack of concentration. Her physical exam is negative. Diagnostic workup concludes ovarian failure. I am referring her to a specialist. Diagnosis: symptomatic postprocedural ovarian failure.
ICD-10-CM Code Assignment.............

Case 2
Clinic Visit
The patient presents today with symptoms of excessive thirst and frequent urination, which has been going on for approximately 1 month. The patient states that these symptoms are affecting her sleep, and she is concerned that there might be something wrong. Patient denies any shortness of breath, nausea, or stomach cramping. The patient does state that her mother had type 2 diabetes, and she is fearful since the symptoms are similar. The patient states that she was borderline diabetic during her pregnancy.
WEIGHT: 198 lb Temp: 98.7 BP: 110/70
HEART: No murmurs, RRR
LUNGS: Normal
SKIN: Warm and dry
EXTREMITIES: No edema
We did a finger stick, which indicated an elevated blood sugar level of 201. An HgA1C was ordered, which came back at a level 9. With these results and the symptoms involved, type 2 diabetes is the diagnosis. We will try to control her diabetes with diet, exercise, and Glucophage. She will be set up for diabetic education as soon as possible.
ICD-10-CM Code Assignment......x...... ,........x......... , .......x.......

Case 3
S: This patient is a 68-year-old female presenting with severe muscle cramps most evenings. Sometimes the cramping wakes her out of a sound sleep. This has been going on for several months and doesn't seem to be getting better.
O: Pleasant older female, well nourished, and in no acute distress. Weight is 175 lb; blood pressure is 176/72; temperature, 98.4; pulse, 72; and respiration, 18. Skin: Normal and dry to touch; no rashes. Heart: No murmurs. Lungs: Clear. Extremities: No edema, clubbing, or cyanosis.
LAB RESULTS: Hemoglobin, 11.6; hematocrit, 35.3; potassium is 5.6, which is slightly elevated.
A & P: Hyperkalemia. I gave the patient a form that lists foods high in potassium content. I asked her to limit her intake of these foods as much as possible. If this approach works and the cramping lessens, we can avoid medication. She is willing to try this for 2 weeks. If she has not improved over that time, we will explore other options.
ICD-10-CM Code Assignment......................

Case 4
This patient presents today with a history of thyroid problems 6 years prior to today's visit. Today she is complaining of some tingling in the hands and feet, some lethargy, and some anxiety. We ran some lab tests, which showed low serum and urinary calcium, as well as low urinary phosphate with increase in the serum phosphate. Parathyroid hormone levels were almost absent. It was determined that the patient has hypoparathyroidism.
ICD-10-CM Code Assignment...............

Case 5
A 2-month-old male presents with chronic, severe diarrhea and fatigue. His growth is stunted. His family is concerned because he has been treated for several different disorders, none of which have been the problem. After extensive lab testing over the last week, we found very low-density lipoprotein levels. We now have a definite diagnosis of Andersen's disease and will begin vitamin E therapy.
ICD-10-CM Code Assignment.............

Case 6
The patient presents today as a follow-up for her type 2 DM with Charcot's joints. There is no change in her medical, family, or social history. On exam, there are no abnormal findings in the cardiac, abdominal, or respiratory systems. Her knees are swollen with instability. Pain is moderate at this time. She is instructed to continue on her current medications with no changes. She is to follow up with me in 4 months.
ICD-10-CM Code Assignment...............
Case 7
Physician's Office Visit
John, a 56-year-old male, presents to the office today to discuss the results of recent laboratory tests.
Chief compliant: Over the last 2 months, John has felt lethargic and drowsy after eating large meals. He complains of extreme thirst and frequent urination.
Physical Exam:
HEENT: All exam areas are within normal limits. His breath has a fruity odor.
Heart: Normal rate and rhythm
Abdomen: Soft, nontender
Extremities: No edema, skin dry and clear
Physical exam is unremarkable
Laboratory Findings: For the last 3 weeks, John has had a fasting plasma glucose level that has been over 140 mg/dL on three of three occasions.
Discussion with Patient: I discussed with John that he has diabetes mellitus. Patient educational information was given and he was referred to the Diabetic Clinic to attend educational classes. He was given information about the need to maintain a well-balanced, nutritious diet. His diabetes will be managed by diet therapy. He is to schedule an appointment and to return to my office in 4 weeks.
Assessment: type 2 diabetes
ICD-10-CM Code Assignment...............

Case 8
Skilled Nursing Facility Visit
This 86-year-old female patient has resided in the facility for 18 months.
Skin: There is a chronic ulceration of the skin of the left heel and midfoot. There is not breakdown into the fatty layer, muscle, or bone.
Assessment: DM, type 2, with skin ulceration on heel and midfoot
ICD-10-CM Code Assignment........x......... , ........x.......
Case 9
Inpatient Progress Note
This 10-year-old male patient is a type 1 diabetic. He was admitted from the emergency room because he is in a coma. He is being seen today for discharge. His insulin levels were adjusted and he can be discharged.
Discharge Diagnosis:
Type 1 diabetes with ketoacidosis with coma
ICD-10-CM Code Assignment........x......... , .......x......

Case 10
Physician's Office Visit
This 69-year-old patient is seen today for type 2 diabetes with diabetic neuropathy, controlled with insulin. The patient was instructed to follow up in 2 months or sooner if glucose levels change.
ICD-10-CM Code Assignment................,................

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Answer #1

Answer:

Case 1 : Symptomatic postprocedural ovarian failure- E89. 41

Case 2 : Type 2 diabetes mellitus - E11. 8

Case 3 : Hyperkalemia - E87. 5

Case 4 : Hypoparathyroidism - E20. 9

Case 5 : Anderson's disease - E75. 21

Case 6 : Type 2 diabetes mellitus with charcot's joint - E11. 610

Case 7 : Type 2 diabetes mellitus - E11. 8

Case 8 : Type 2 diabetes mellitus- E11. 8

Skin ulceration on heel and midfoot - L97. 409

Case 9 : Type 1 diabetes mellitus - E10. 9

Ketoacidosis with coma - E10. 11

Case 10 : Type 2 diabetes with diabetic neuropathy - E11. 40

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