Deck 5: Chapter-Specific Guidelines ICD-10-CM Chapters 1-10
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Deck 5: Chapter-Specific Guidelines ICD-10-CM Chapters 1-10
1
If a patient with coronary artery disease is admitted due to an acute myocardial infarction (AMI), the AMI should be sequenced before the coronary artery disease.
True
2
Septic shock does not indicate the presence of severe sepsis.
False
3
If the type of diabetes mellitus is not documented in the medical record, the default is type 2 diabetes mellitus.
True
4
When the reason for the encounter is to determine the extent of the malignancy, or for a procedure such as paracentesis or thoracentesis, the primary malignancy or appropriate metastatic site is designated as the first-listed diagnosis.
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5
Central pain and chronic pain have the same meaning.
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6
Mood disorders are also known as affective disorders with the main characteristic of disturbance in mood, most commonly anxiety, depression, and bipolar disorders.
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7
The secondary cancer should be listed before the primary cancer if the secondary cancer is the reason for the visit.
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8
Entropion is the outward turning of the margin of the eyelid.
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9
I-10 presumes a cause-and-effect relationship between hypertension and acute kidney disease.
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10
A code from subcategory R65.2, Severe sepsis, should not be assigned unless severe sepsis or an associated acute organ dysfunction is documented.
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11
G89 category codes (Pain) can be assigned as the first-listed or primary diagnoses.
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12
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.
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13
If a patient is admitted for dehydration due to chemotherapy, the dehydration is the first-listed diagnosis.
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14
The Eustachian tube is part of the inner ear.
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15
If a patient is seen for a pathological fracture due to a neoplasm, the neoplasm should be the first-listed diagnosis.
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16
A STEMI is also known as a Q-wave or transmural myocardial infarction.
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17
Identify all infections documented as antibiotic resistant with code Z16.-, Infection with drug resistant microorganisms, which is placed before the infection code.
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18
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.
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19
If the patient has documented HIV, the HIV must be the first-listed diagnosis even if the patient is seen for a condition unrelated to HIV.
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20
I-10 presumes a cause-and-effect relationship between hypertension and heart and renal disease.
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21
Malignant hypertension with stage 4 chronic kidney disease.
ICD-10-CM Codes: ____________________ (two codes)
ICD-10-CM Codes: ____________________ (two codes)
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22
Hypertensive congestive heart failure with hypertension and chronic kidney disease, stage 4.
ICD-10-CM Codes: ____________________ (three codes)
ICD-10-CM Codes: ____________________ (three codes)
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23
Primary malignancy of the left tonsil.
ICD-10-CM Code: ____________________
ICD-10-CM Code: ____________________
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24
Acute lower respiratory infection (Streptococcus, group A) in a patient with COPD.
ICD-10-CM Codes: ____________________ (two codes)
ICD-10-CM Codes: ____________________ (two codes)
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25
Cataract due to type 2 diabetes mellitus.
ICD-10-CM Code: ____________________
ICD-10-CM Code: ____________________
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26
Post-traumatic acute headache.
ICD-10-CM Code: ____________________
ICD-10-CM Code: ____________________
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27
Treatment for anemia due to non-Hodgkin lymphoma.
ICD-10-CM Codes: ____________________ (two codes)
ICD-10-CM Codes: ____________________ (two codes)
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28
Admission for pain control for liver cancer.
ICD-10-CM Codes: ____________________ (two codes)
ICD-10-CM Codes: ____________________ (two codes)
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29
Infectious colitis.
ICD-10-CM Code: _____________________
ICD-10-CM Code: _____________________
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30
Acute bilateral lacrimal canaliculitis due to Staphylococcus aureus.
ICD-10-CM Codes: ____________________ (two codes)
ICD-10-CM Codes: ____________________ (two codes)
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31
Stenosis of the left carotid artery causing infarction/occlusion of a cerebral artery.
ICD-10-CM Code: ____________________
ICD-10-CM Code: ____________________
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32
Arthritis due to Lyme disease.
ICD-10-CM Code: ____________________
ICD-10-CM Code: ____________________
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33
Acute suppurative otitis media without rupture of eardrum, of the left ear.
ICD-10-CM Code: ____________________
ICD-10-CM Code: ____________________
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34
Acute rheumatic mitral and aortic valve disease.
ICD-10-CM Code: ____________________
ICD-10-CM Code: ____________________
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35
Atherosclerotic coronary artery disease with history of stent placement via angioplasty in the native right coronary artery.
ICD-10-CM Codes: ____________________ (two codes)
ICD-10-CM Codes: ____________________ (two codes)
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36
Melkersson-Rosenthal syndrome.
ICD-10-CM Code: ____________________
ICD-10-CM Code: ____________________
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37
Pleural plaque without asbestos.
ICD-10-CM Code: ____________________
ICD-10-CM Code: ____________________
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38
Retinal migraine.
ICD-10-CM Code: ____________________
ICD-10-CM Code: ____________________
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39
Encounter for screening for HIV due to high-risk heterosexual behavior.
ICD-10-CM Codes: ____________________ (two codes)
ICD-10-CM Codes: ____________________ (two codes)
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40
Acute lymphangitis of left upper arm.
ICD-10-CM Code: ____________________
ICD-10-CM Code: ____________________
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41
Primary lung cancer of the right middle lobe with metastasis to the neck of the pancreas.
ICD-10-CM Codes: ____________________ (two codes)
ICD-10-CM Codes: ____________________ (two codes)
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42
Prinzmetal angina.
ICD-10-CM Code: _____________________
ICD-10-CM Code: _____________________
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43
Type 1 diabetes mellitus with unspecified diabetic retinopathy and with diabetic cataract.
ICD-10-CM Codes: ____________________ (two codes)
ICD-10-CM Codes: ____________________ (two codes)
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44
Intractable epileptic seizures related to alcohol.
ICD-10-CM Code: ____________________
ICD-10-CM Code: ____________________
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45
Sick sinus syndrome.
ICD-10-CM Code: _____________________
ICD-10-CM Code: _____________________
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46
Mitral valve prolapse, nonrheumatic.
ICD-10-CM Code: ____________________
ICD-10-CM Code: ____________________
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47
Otomycosis due to aspergillosis.
ICD-10-CM Code: _____________________
ICD-10-CM Code: _____________________
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48
Unspecified thyrotoxicosis with thyrotoxic storm.
ICD-10-CM Code: _____________________
ICD-10-CM Code: _____________________
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49
COPD with acute exacerbation.
ICD-10-CM Code: _____________________
ICD-10-CM Code: _____________________
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50
Sickle-cell anemia.
ICD-10-CM Code: ____________________
ICD-10-CM Code: ____________________
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51
Bifascicular block.
ICD-10-CM Code: _____________________
ICD-10-CM Code: _____________________
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52
Sickle-cell crisis with acute chest syndrome.
ICD-10-CM Code: _____________________
ICD-10-CM Code: _____________________
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53
Psychogenic dysphonia.
ICD-10-CM Code: ____________________
ICD-10-CM Code: ____________________
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54
Buerger's disease.
ICD-10-CM Code: _____________________
ICD-10-CM Code: _____________________
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55
Chronic asthmatic bronchitis with COPD.
ICD-10-CM Code: _____________________
ICD-10-CM Code: _____________________
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56
Encounter for chemotherapy for malignant glioma of the frontal lobe.
ICD-10-CM Codes: ____________________ (two codes)
ICD-10-CM Codes: ____________________ (two codes)
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57
Benign neoplasm of the thymus.
ICD-10-CM Code: _____________________
ICD-10-CM Code: _____________________
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58
Encounter for treatment of pancytopenia due to primary angiosarcoma of the liver.
ICD-10-CM Codes: ____________________ (two codes)
ICD-10-CM Codes: ____________________ (two codes)
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59
Ulcer with necrosis of the muscle of the left ankle, due to atherosclerosis of native vessel of the left leg.
ICD-10-CM Codes: ____________________ (two codes)
ICD-10-CM Codes: ____________________ (two codes)
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60
Diabetes insipidus.
ICD-10-CM Code: ____________________
ICD-10-CM Code: ____________________
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61
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): ____________________
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): ____________________
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62
Primary malignant neoplasm of the gallbladder.
ICD-10-CM Code: ____________________
ICD-10-CM Code: ____________________
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63
Candidal infection of the mouth.
ICD-10-CM Code: ____________________
ICD-10-CM Code: ____________________
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64
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): ____________________
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): ____________________
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65
Congestive heart failure.
ICD-10-CM Code: ____________________
ICD-10-CM Code: ____________________
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