Chapter 4: Practical Application
This patient is a 50-year-old female who began developing bleeding, bright red blood per
rectum (Patient's presenting complaint.), approximately two weeks ago. She is referred by her
family physician. She states that after a bowel movement she noticed blood in the toilet. She
denied any prior history of bleeding or pain with defecation. She states that she has had an
external hemorrhoid (This is reported by the patient, but not documented in the exam or
assessment, so it is not coded.) that did bleed at times but that is not where this bleeding is
coming from. She is presently concerned because a close friend of hers was recently diagnosed
with rectal carcinoma requiring chemotherapy that was missed by her primary doctor. She is
here today for evaluation for a colonoscopy.
Physical examination, she appears to be a well appearing 50-year-old, white female. Abdomen is
soft, non-tender, non-distended.
ASSESSMENT: 50 year- - Answer K62.5
Use the Assessment to determine the diagnosis. The patient is seen to evaluate her rectal
bleeding and determine the course of action. The patient is not seen to determine if she is in a
condition to withstand surgery.
PREOPERATIVE DIAGNOSIS: Bilateral profound sensorineural hearing loss.
POSTOPERATIVE DIAGNOSIS: Bilateral profound sensorineural hearing loss.(Report the
postoperative diagnosis.)
PROCEDURES PERFORMED:
1. Placement of left Nucleus cochlear implant.
2. Facial nerve monitoring for an hour.
3. Microscope use.
ANESTHESIA: General.
INDICATIONS: This is a 69-year-old woman who has had progressive hearing loss (The diagnosis
is documented as the indication for the
surgery.) over the last 10-15 years. Hearing aids are not useful for her. She is a candidate for
cochlear implant by FDA standards. The risks, benefits, and alternatives of procedure were
described to the patient, who voiced understanding and wished to proceed.
PROCEDURE: After properly identifying the patient, she was taken to the main operating room,
where general anesthetic was induced. The table was turned to 180 degrees and a standard left-
sided post auricula - Answer H90.3
There are different types of hearing loss; this patient has sensorineural hearing loss. In the
Alphabetic Index, look for Loss/hearing (see also Deafness). Locate
Deafness/sensorineural/bilateral.
CC: HTN
INTERVAL HISTORY: No new complaints.
, EXAM: NAD. 130/80, 84, 22. Lungs are clear. Heart RRR, no MRGs. Abdomen is soft, non-tender.
No peripheral edema.
IMPRESSION: Stable HTN(Patient is diagnosed with hypertension.) on current meds.
PLAN: No changes needed. RTC in six months with labs.
What diagnosis code(s) are reported? - Answer I10
The abbreviation HTN means hypertension.
SUBJECTIVE: Low-grade fever at home. She has had some lumps in the abdominal wall and
when she injects her insulin; it does seem to hurt there. She stopped four of her medications
including Neurontin, Depakote, Lasix, and Premarin, and overall, she feels quite well.
Unfortunately, she has put on 20 pounds since our last visit.
OBJECTIVE:
HEENT: Tympanic membranes are retracted but otherwise clear. The nose shows significant
green rhinorrhea present. Throat is mildly inflamed with moderate postnasal drainage.
Neck: No significant adenopathy.
Lungs: Clear.
Heart: Regular rate and rhythm.
Abdomen: Soft, obese, and nontender. Multiple lipomas are palpated.
ASSESSMENT
1. Diabetes mellitus, type 1.
2. Diabetic neuropathy.
3. Acute sinusitis.
(The definitive diagnoses are reported.)
PLAN: At this time, I have recommended the addition of Keflex for her acute sinusitis.(Provider
treated the acute sinusitis.) I have given her - Answer E10.40, J01.90
Review the ICD-10-CM Official guidelines for coding diabetes with a diabetic manifestation
(Section I.C.4.a). The 2nd code is acute sinusitis.
PREOPERATIVE DIAGNOSIS: Cataract, left eye
POSTOPERATIVE DIAGNOSIS: Cataract left eye, Presbyopia(Report the postoperative diagnosis.)
PROCEDURE:
1. Cataract extraction with IOL implant
2. Correction of presbyopia(Patient is also diagnosed with presbyopia.) with lens implantation
PROCEDURE DETAIL: The patient was brought to the operating room under neuroleptic
anesthesia monitoring. A topical anesthetic was placed within the operative eye and the patient
was prepped and draped in usual manner for sterile ophthalmic surgery. A lid speculum was
inserted into the right infrapalpebral space. A 6-0 silk suture was placed through the episclera at
12 o'clock. A subconjunctival injection of non-preserved lidocaine was given. A peritomy was
fashioned from 11 o'clock to 1 o'clock with Westcott scissors. Hemostasis was achieved with the
This patient is a 50-year-old female who began developing bleeding, bright red blood per
rectum (Patient's presenting complaint.), approximately two weeks ago. She is referred by her
family physician. She states that after a bowel movement she noticed blood in the toilet. She
denied any prior history of bleeding or pain with defecation. She states that she has had an
external hemorrhoid (This is reported by the patient, but not documented in the exam or
assessment, so it is not coded.) that did bleed at times but that is not where this bleeding is
coming from. She is presently concerned because a close friend of hers was recently diagnosed
with rectal carcinoma requiring chemotherapy that was missed by her primary doctor. She is
here today for evaluation for a colonoscopy.
Physical examination, she appears to be a well appearing 50-year-old, white female. Abdomen is
soft, non-tender, non-distended.
ASSESSMENT: 50 year- - Answer K62.5
Use the Assessment to determine the diagnosis. The patient is seen to evaluate her rectal
bleeding and determine the course of action. The patient is not seen to determine if she is in a
condition to withstand surgery.
PREOPERATIVE DIAGNOSIS: Bilateral profound sensorineural hearing loss.
POSTOPERATIVE DIAGNOSIS: Bilateral profound sensorineural hearing loss.(Report the
postoperative diagnosis.)
PROCEDURES PERFORMED:
1. Placement of left Nucleus cochlear implant.
2. Facial nerve monitoring for an hour.
3. Microscope use.
ANESTHESIA: General.
INDICATIONS: This is a 69-year-old woman who has had progressive hearing loss (The diagnosis
is documented as the indication for the
surgery.) over the last 10-15 years. Hearing aids are not useful for her. She is a candidate for
cochlear implant by FDA standards. The risks, benefits, and alternatives of procedure were
described to the patient, who voiced understanding and wished to proceed.
PROCEDURE: After properly identifying the patient, she was taken to the main operating room,
where general anesthetic was induced. The table was turned to 180 degrees and a standard left-
sided post auricula - Answer H90.3
There are different types of hearing loss; this patient has sensorineural hearing loss. In the
Alphabetic Index, look for Loss/hearing (see also Deafness). Locate
Deafness/sensorineural/bilateral.
CC: HTN
INTERVAL HISTORY: No new complaints.
, EXAM: NAD. 130/80, 84, 22. Lungs are clear. Heart RRR, no MRGs. Abdomen is soft, non-tender.
No peripheral edema.
IMPRESSION: Stable HTN(Patient is diagnosed with hypertension.) on current meds.
PLAN: No changes needed. RTC in six months with labs.
What diagnosis code(s) are reported? - Answer I10
The abbreviation HTN means hypertension.
SUBJECTIVE: Low-grade fever at home. She has had some lumps in the abdominal wall and
when she injects her insulin; it does seem to hurt there. She stopped four of her medications
including Neurontin, Depakote, Lasix, and Premarin, and overall, she feels quite well.
Unfortunately, she has put on 20 pounds since our last visit.
OBJECTIVE:
HEENT: Tympanic membranes are retracted but otherwise clear. The nose shows significant
green rhinorrhea present. Throat is mildly inflamed with moderate postnasal drainage.
Neck: No significant adenopathy.
Lungs: Clear.
Heart: Regular rate and rhythm.
Abdomen: Soft, obese, and nontender. Multiple lipomas are palpated.
ASSESSMENT
1. Diabetes mellitus, type 1.
2. Diabetic neuropathy.
3. Acute sinusitis.
(The definitive diagnoses are reported.)
PLAN: At this time, I have recommended the addition of Keflex for her acute sinusitis.(Provider
treated the acute sinusitis.) I have given her - Answer E10.40, J01.90
Review the ICD-10-CM Official guidelines for coding diabetes with a diabetic manifestation
(Section I.C.4.a). The 2nd code is acute sinusitis.
PREOPERATIVE DIAGNOSIS: Cataract, left eye
POSTOPERATIVE DIAGNOSIS: Cataract left eye, Presbyopia(Report the postoperative diagnosis.)
PROCEDURE:
1. Cataract extraction with IOL implant
2. Correction of presbyopia(Patient is also diagnosed with presbyopia.) with lens implantation
PROCEDURE DETAIL: The patient was brought to the operating room under neuroleptic
anesthesia monitoring. A topical anesthetic was placed within the operative eye and the patient
was prepped and draped in usual manner for sterile ophthalmic surgery. A lid speculum was
inserted into the right infrapalpebral space. A 6-0 silk suture was placed through the episclera at
12 o'clock. A subconjunctival injection of non-preserved lidocaine was given. A peritomy was
fashioned from 11 o'clock to 1 o'clock with Westcott scissors. Hemostasis was achieved with the
