Exam 11: Extension 1: Exam-Specific Guidelines: ICD-10-CM Chapters 1-10

Malignant hypertension with stage 4 chronic kidney disease. ICD-10-CM Codes: ____________________, ____________________

Prinzmetal angina. ICD-10-CM Code: _____________________

A code from category G89 (Pain) should not be assigned if the underlying (definitive) diagnosis is known unless the reason for the encounter is pain control/management.

Identify all infections documented as antibiotic resistant with code Z16.-, Infection with drug resistant microorganisms, which is placed before the infection code.

A STEMI is also known as a Q-wave or transmural myocardial infarction.

If the type of diabetes mellitus is not documented in the medical record, the default is type 2 diabetes mellitus.

Otomycosis due to aspergillosis. ICD-10-CM Code: _____________________

Stenosis of the left carotid artery causing infarction/occlusion of a cerebral artery. ICD-10-CM Code: ____________________

Code C80.0, Disseminated malignant neoplasm, unspecified, is reported only in those cases where the patient has advanced metastatic disease and no known primary or secondary sites are specified.

Mitral valve prolapse, nonrheumatic. ICD-10-CM Code: ____________________

Type 1 diabetes mellitus with unspecified diabetic retinopathy and with diabetic cataract. ICD-10-CM Codes: ____________________, ____________________

Sickle-cell anemia. ICD-10-CM Code: ____________________

Chronic asthmatic bronchitis with COPD. ICD-10-CM Code: _____________________

HOSPITAL-RECORD OF OPERATION INDICATION: Septic shock due to severe sepsis and the need to initiate mechanical ventilation. PROCEDURE PERFORMED: Elective intubation. ANESTHESIA: Versed and fentanyl. PROCEDURE: After the procedure was explained to and consent was obtained from the patient's family, the patient was premedicated with Versed and fentanyl. After adequate anesthesia and analgesia was achieved, the patient's vocal cords were directly visualized with the aid of a laryngoscope using a Miller 3 blade. A size 8.5 endotracheal tube was then inserted and passed through the vocal cords atraumatically and without any difficulty. The CO₂ monitor did confirm correct placement of the tube. The cuff was then inflated and the tube secured around 22 cm at the lips. The patient tolerated the procedure well. There were no acute complications. A chest x-ray had been ordered to confirm correct placement of the endotracheal tube. ICD-10-CM Code(s): ____________________

RECORD OF OPERATION PREOPERATIVE DIAGNOSIS: Acute myocardial infarction, congestive heart failure with hypotension. POSTOPERATIVE DIAGNOSIS: Same. PROCEDURE_.PERFORMED: Insertion of Swan-Ganz catheter. PROCEDURE: Right neck area was prepped. Sterile drapes were applied. Under sterile gowns and technique, right internal jugular vein was identified with 22 gauge needle from medial approach. 18 gauge catheter was inserted into the vein. A guide wire was passed through the vein. 9 French introducer was inserted over the guide wire without difficulty. 7.5 French catheter was inserted. Right atrial pressures were 16, right ventricular pressure 34/10, pulmonary artery pressure 36/22 with a wedge pressure of 18. The patient tolerated the procedure well. ICD-10-CM Code(s): ____________________

The secondary cancer should be listed before the primary cancer if the secondary cancer is the reason for the visit.

Intractable epileptic seizures related to alcohol. ICD-10-CM Code: ____________________

Infectious colitis. ICD-10-CM Code: _____________________

Acute bilateral lacrimal canaliculitis due to Staphylococcus aureus. ICD-10-CM Codes: ____________________, ____________________

Atherosclerotic coronary artery disease with history of stent placement via angioplasty in the native right coronary artery. ICD-10-CM Codes: ____________________, _____________________