is admitted to Westward Hospital for a fetal skin transplantation, via
natural opening.
Explanation
Principal Procedure:
Where should you begin to look up the code in the coding manual - ICD-10-PCS Alphabetic
Index
What is the type of procedure - Transplantation
What type - Products of conception
What is the character 1: Section Character - 1
What is the character 2: Body System Character - 0
What is the character 3: Root Operation Character - Y
What is the character 4: Body Part Character - 0
What is the character 5: Approach Character - 7
What is the character 6: Device Character - Z
What is the character 7: Qualifier Character - Q
What is the correct code: 10Y07ZQ
Ira Morgan, a 16-month-old male, was brought to radiology for a
real-time, limited, static ultrasound of his hips.
Explanation
Principal Procedure:
Where should you begin to look up the code in the coding manual - CPT Alphabetic Index
What type of procedure - Ultrasound
What is the anatomic site - Hip
What is the age of the patient - 16 months
What else do we know about it - Limited, static (other answer options: dynamic)
Begin to code the encounter
Did you verify the code in the numerical listing - Yes
Is there a symbol for this code - No
If so what does the symbol mean - Does not apply
Is there an additional notation - No
If so does the notation apply - Does not apply
Do you need to add a modifier - No
If so what is the modifier - Does not apply
Did you check the guidelines - Yes
Did you code to the highest level of specificity - Yes
What is the correct procedure code - 76886
,Edith Shapin, a 24-year-old female, is pregnant for the first time and
is at approximately 11 weeks gestation. She is brought into the
diagnostic center for a fetal biophysical profile with nonstress
testing.
Explanation
Principal Procedure:
Where should you begin to look up the code in the coding manual - CPT Alphabetic Index
What type of procedure - Fetal nonstress test
What is the type of diagnostic test used - Ultrasound
Begin to code the encounter
Did you verify the code in the numerical listing - Yes
Is there a symbol for this code - No
If so what does the symbol mean - Does not apply
Is there an additional notation - No
If so does the notation apply - Does not apply
Do you need to add a modifier - No
If so what is the modifier - Does not apply
Did you check the guidelines - Yes
Did you code to the highest level of specificity - Yes
What is the correct procedure code - 76818
Keyana Haulbrook, a 17-year-old female, G1 P0, 12 weeks gestation,
is admitted to Westward Hospital to terminate pregnancy due to a
genetic defect in the fetus. Abortion was performed by hysterotomy
technique.
Explanation
Principal Procedure:
Where should you begin to look up the code in the coding manual - ICD-10-PCS Alphabetic
Index
What is the type of procedure - Termination of pregnancy
How is the procedure performed - Hysterotomy
What is the character 1: Section Character - 1
What is the character 2: Body System Character - 0
What is the character 3: Root Operation Character - A
What is the character 4: Body Part Character - 0
What is the character 5: Approach Character - 0
What is the character 6: Device Character - Z
What is the character 7: Qualifier Character - Z
What is the correct code: 10A00ZZ
,Ross Risinger, a 47-year-old male, presents today for screening of a
malignant neoplasm of the prostate. Ross’s grandfather died of
prostate cancer. Dr. Richardson completes the appropriate test;
results were negative.
Explanation
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 - Screening
What type - Neoplasm
What is the location - Prostate
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 - Yes
If so does the Use additional code note apply to the case study - Yes
Is there an Excludes1 notation - Yes
If so does the Excludes1 note apply to the case study - No
Is there an Excludes2 notation - No
If so does the Excludes2 note apply to the case study - No Excludes2 notation
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 - Z12.5
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 - History
What type - Family
What type - Malignant
What is the anatomical site - Prostate
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 - Yes
If so does the Code also note apply to the case study - No
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 Excludes1 notation
Is there an Excludes2 notation - No
If so does the Excludes2 note apply to the case study - No Excludes2 notation
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 - Z80.42
Sam Goodman, a 9-year-old male, presents today for a sports
physical in order to play on his school baseball team. Dr. Inabinet
notes splenomegaly. The results from the CBC test and peripheral
blood smear confirm a diagnosis of Hb-C disease.
Explanation
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 – Disease
What type – hemoglobin
What type - C
Do any of the following apply to the condition – None of these
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 – D58.2