Chapter 5: Practical Application
CASE 1
Office note:
RE: Injection, strapping of foot and ankle.
Chief complaint: heel pain(Patient complaint.), 6 months' duration. No inflammation, no heat.
Diagnosis: Heel spur.(Definitive diagnosis. The heel pain is a symptom of a heel spur.)
Treatment: Weight reduction, injection of Celestone, Xylocaine plain, pulses good, DTR,
vibration and temp normal.
Orthotics suggested; better shoes suggested. Lawyer by trade. Criminal trial attorney. Referred
by his partner. Discussed diet, orthoti - Answer M77.30
CASE 2
Reason for consult: Acute renal failure (Indication for the visit.)
HPI: The patient was followed in the past by my associate for CKD, with baseline creatinine of
1.8 two weeks ago. Found to have severe ARF this morning associated with acidosis and
moderate hyperkalemia after presenting to the ER with complaint of dehydration. (These
conditions werediagnosed by another physician in the emergency room.) The patient is
admitted under observation status to the hospitalist service and the ren - Answer N17.9
E86.0 N18.30 I95.9
Response Feedback:
There are four ICD-10-CM codes reported. The primary reason for the visit is Acute Renal Failure
due to dehydration. Impression number 1 indicates the first two codes. The third code is for
stage III CKD (chronic kidney disease). Stage 3 CKD is a 5th character code depending on a
specified stage. The documentation does not specify 3a or 3b and would be reported
unspecified. Hypotension is the fourth code. The type of hypotension is not specified - pay
attention to the 4th character.
CASE 3
PROGRESS NOTE
Chief complaint: Multiple ulcers.
Subjective: The patient returns, accompanied by her caregiver who states that she believes the
ulcers have gotten "about as good as they are going to." The edema of the leg seems to be
controlled much better.
, Objective: Exam reveals marked improvement of the edema (The edema is improving.) of both
lower legs, the right is better than the left. All of the ulcers are now extremely superficial and
seem to almost be partial thickness skin.(T - Answer L97.521 L97.511 R60.0 M79.672
There are four ICD-10-CM codes reported. Follow the order of the Assessment. The primary
reason for the visit is ulcers on the feet. The progress note does not indicate if the ulcers are
pressure ulcers or decubitus ulcers; they are superficial involving skin breakdown. Start in the
ICD-10-CM Alphabetic Index with Ulcer/lower limb/foot. You will have one code for each foot.
Edema is still present in the lower extremities and is the third diagnosis. Look for Edema/legs.
Foot pain is the fourth diagnosis. Look for Pain/limb/lower/foot. You will need a 6th character
for laterality.
CASE 4
Subjective: The patient presents today after having a cabinet fall on her.(This describes how the
injury occurred.) She states the people who put in the cabinet missed the stud by about two
inches. The patient complains of cephalgia,(Patient complaint.) primarily occipital, extending up
into the bilateral occipital and parietal regions. The patient denies any vision changes, any taste
changes or any smell changes. The patient has marked amount of tenderness across the
superior trapezius.( - Answer R51.9 M99.02 W20.8XXA
Response Feedback:
There are three ICD-10-CM codes reported. The reason for the visit is cephalgia. The
documentation doesn't report what part of the body was hit by the cabinet and the cephalgia
would not be considered - or meet the requirements - of post-traumatic cephalgia. The second
diagnosis is thoracic somatic dysfunction. In the ICD-10-CM Alphabetic Index look for
dysfunction/somatic/thoracic. The documentation indicates how the injury occurred; select an
External Cause Code. The External Cause Codes have their own index - External Cause of Injuries
Index. The patient was "Struck" by a falling object (cabinet). Use the External Cause of Injuries
Index to find the External Cause code for Struck by/object/falling. Make sure you read the
instructional notes and are code to the 7th character when appropriate. Coding guideline,
Section I.C.20.a.6. has instructions on how to sequence External Cause codes.
CASE 5
CHIEF COMPLAINT: Right shoulder injury.(Patient's complaint.)
MODE OF ARRIVAL: Private vehicle.
HISTORY OF PRESENT ILLNESS: The patient is a 59-year-old male who states that just prior to
arrival he was going into a supermarket (Where accident occurred) when the revolving door
suddenly slammed on him(How accident happened). It caught him across the right side of his
chest anteriorly and posteriorly.(Location of the chest injury.) He was unable to liberate himself
from the door, and an e - Answer S20.211A S20.221A S49.91XA W23.0XXA Y92.512
Response Feedback:
CASE 1
Office note:
RE: Injection, strapping of foot and ankle.
Chief complaint: heel pain(Patient complaint.), 6 months' duration. No inflammation, no heat.
Diagnosis: Heel spur.(Definitive diagnosis. The heel pain is a symptom of a heel spur.)
Treatment: Weight reduction, injection of Celestone, Xylocaine plain, pulses good, DTR,
vibration and temp normal.
Orthotics suggested; better shoes suggested. Lawyer by trade. Criminal trial attorney. Referred
by his partner. Discussed diet, orthoti - Answer M77.30
CASE 2
Reason for consult: Acute renal failure (Indication for the visit.)
HPI: The patient was followed in the past by my associate for CKD, with baseline creatinine of
1.8 two weeks ago. Found to have severe ARF this morning associated with acidosis and
moderate hyperkalemia after presenting to the ER with complaint of dehydration. (These
conditions werediagnosed by another physician in the emergency room.) The patient is
admitted under observation status to the hospitalist service and the ren - Answer N17.9
E86.0 N18.30 I95.9
Response Feedback:
There are four ICD-10-CM codes reported. The primary reason for the visit is Acute Renal Failure
due to dehydration. Impression number 1 indicates the first two codes. The third code is for
stage III CKD (chronic kidney disease). Stage 3 CKD is a 5th character code depending on a
specified stage. The documentation does not specify 3a or 3b and would be reported
unspecified. Hypotension is the fourth code. The type of hypotension is not specified - pay
attention to the 4th character.
CASE 3
PROGRESS NOTE
Chief complaint: Multiple ulcers.
Subjective: The patient returns, accompanied by her caregiver who states that she believes the
ulcers have gotten "about as good as they are going to." The edema of the leg seems to be
controlled much better.
, Objective: Exam reveals marked improvement of the edema (The edema is improving.) of both
lower legs, the right is better than the left. All of the ulcers are now extremely superficial and
seem to almost be partial thickness skin.(T - Answer L97.521 L97.511 R60.0 M79.672
There are four ICD-10-CM codes reported. Follow the order of the Assessment. The primary
reason for the visit is ulcers on the feet. The progress note does not indicate if the ulcers are
pressure ulcers or decubitus ulcers; they are superficial involving skin breakdown. Start in the
ICD-10-CM Alphabetic Index with Ulcer/lower limb/foot. You will have one code for each foot.
Edema is still present in the lower extremities and is the third diagnosis. Look for Edema/legs.
Foot pain is the fourth diagnosis. Look for Pain/limb/lower/foot. You will need a 6th character
for laterality.
CASE 4
Subjective: The patient presents today after having a cabinet fall on her.(This describes how the
injury occurred.) She states the people who put in the cabinet missed the stud by about two
inches. The patient complains of cephalgia,(Patient complaint.) primarily occipital, extending up
into the bilateral occipital and parietal regions. The patient denies any vision changes, any taste
changes or any smell changes. The patient has marked amount of tenderness across the
superior trapezius.( - Answer R51.9 M99.02 W20.8XXA
Response Feedback:
There are three ICD-10-CM codes reported. The reason for the visit is cephalgia. The
documentation doesn't report what part of the body was hit by the cabinet and the cephalgia
would not be considered - or meet the requirements - of post-traumatic cephalgia. The second
diagnosis is thoracic somatic dysfunction. In the ICD-10-CM Alphabetic Index look for
dysfunction/somatic/thoracic. The documentation indicates how the injury occurred; select an
External Cause Code. The External Cause Codes have their own index - External Cause of Injuries
Index. The patient was "Struck" by a falling object (cabinet). Use the External Cause of Injuries
Index to find the External Cause code for Struck by/object/falling. Make sure you read the
instructional notes and are code to the 7th character when appropriate. Coding guideline,
Section I.C.20.a.6. has instructions on how to sequence External Cause codes.
CASE 5
CHIEF COMPLAINT: Right shoulder injury.(Patient's complaint.)
MODE OF ARRIVAL: Private vehicle.
HISTORY OF PRESENT ILLNESS: The patient is a 59-year-old male who states that just prior to
arrival he was going into a supermarket (Where accident occurred) when the revolving door
suddenly slammed on him(How accident happened). It caught him across the right side of his
chest anteriorly and posteriorly.(Location of the chest injury.) He was unable to liberate himself
from the door, and an e - Answer S20.211A S20.221A S49.91XA W23.0XXA Y92.512
Response Feedback:
