CRC CASE STUDIES 1 QUESTIONS AND
ANSWERS LATEST REVIEW
ANS:
N18.6,AI12.0,AE10.22,AE10.40,AE10.319,AZ99.2,AI70.209,AE78.00,AM81.0,AZ94.0,AZ94.83
Rationale:AInAthisAexampleAtheApatientAhasAhypertensionAandAendAstageArenalAdisease.AAc
cordingAtoAtheAICD-10-
CMAguidelineAI.C.9.a.2,AAssignAcodesAfromAcategoryAI12,AHypertensiveAchronicAkidneyAdi
sease,AwhenAbothAhypertensionAandAaAconditionAclassifiableAtoAcategoryAN18,AChronicAkid
neyAdiseaseA(CKD),AareApresent.AICD-10-CMApresumesAaAcause-and-
effectArelationship.AToAlocateAthisAcode,AlookAinAtheAAlphabeticAIndexAforAHypertension/wit
h/kidney/with/stageA5AchronicAkidneyAdiseaseA(CKD)AorAendAstageArenalAdiseaseA(ESRD)A
I12.0.AThereAisAanAinstructionalAnoteAthatAstatesAtoA"UseAadditionalAcodeAtoAidentifyAtheAsta
geAofAchronicAkidneyAdiseaseA(N18.5,AN18.6).AInAthisAcaseAtheApatientAhasAendAstageArena
lAdiseaseAsoAN18.6AisAassigned.ATheApatientAisAalsoAaAtypeA1AdiabeticAwithAdiabeticAretinop
athyAandAdiabeticAneuropathy.ACombinationAcodesA-ACORRECTAANSWERSA-
1.ATRANSPLANTASURGERY
Mr.AXAisAaA66Ayear-
oldAwhiteAmaleAwhoAhadAendAstageArenalAdiseaseAandAtypeAIAdiabetesAmellitusAandAunder
wentAcombinedAkidneyAandApancreasAtransplantation.AHeAlostAhisArenalAallograftAfromABKA
viralAnephropathyAandAunderwentAretransplantationAtenAyearsAago.AHeAhadAproblemsAwith
ArenalAallograftAdysfunctionAandAunderwentApercutaneousArenalAallograftAbiopsyAelevenAye
arsAago,AwhichArevealedAhypertensiveAchangesAwithinAhisAkidney.AHeArecentlyAhadAhisAlisi
noprilAdiscontinued.
HisAbloodApressuresAagainAclimbedAtoAanAunacceptableAlevel.AHeAhadAatenololAadded.AHe
AstatesAthatAhisApulseAhasAslowedAdownAwithAtheAatenolol.AHeAhasAhadAnoAtroubleAwithAdiz
ziness.AHeAbringsAhisAbloodApressureAcuffAwithAhimAtoday.AHisAcuffAreadsA170/90.AMyAread
ingAwithAtheAelectronicAcuffAisA173/84.AIAamAunableAtoAauscultateAaApressureAinAthisApatient
.AHisAlogAofAhisAbloodApressureAreadingsAatAhomeAinAtheAstandingApositionAareAusuallyAinAth
eA130Arange.AIAfeelAthatAthisAisAanAacceptableAbloodApressureAforAthisApatient.AWeAwillAaddA
noAadditionalAantihypertensiveAmedicines.
LABORATORYAREVIEWA(xx/xx/20xx)
SodiumA144;ApotassiumA5.0;AchlorideA109;AcarbonAdioxideA20;AwhiteAcount
7000;AhematocritA31.9;AplateletAcountA264,000;ABUNA43;AcreatinineA1.82;
PrografAlevelA6.4;AamylaseA28;AlipaseA69.
ASSESSMENT:
1.AHypertensionA-AreasonablyAcontrolled.
2.AEndAstageArenalAdisease.AOnAdialysis.
3.ADiabetesAmellitusAtypeAI.
4.ADiabeticAretinopathyA-Astable.
5.ADiabeticAneuropathy.
6.ABKAallograftAnephropathy.
,7.ARenalAallograftArejectionA-AJuneA1999.
8.AHypercholesterolemia.
9.AAtherosclerosis,Aextremities.
10.AOsteoporosis.
PLAN:
TheApatientAisAtoAcontinueAonAtheAcurrentAantihypertensiveAregimen.AWeAwillAscheduleAhim
AforAaAboneAdensitometryAstudyAonAhisAreturn.AHeAisAprovidedAthreeAcardsAforAstoolAsampli
ngAforAguaiacAtesting.AHeAisAtoAgetAaAbloodAcheck
ANS:
Z00.01,AZ89.511,AE11.9,AI10,AG54.6,AZ68.28,AZ79.82,AZ82.0,AZ83.3,AZ79.84
Rationale:AInAthisAcase,AtheApatientApresentsAforAaAcomprehensiveAmedicalAexamination.A
LookAinAtheAAlphabeticAIndexAforAExamination/withAabnormalAfindingsAwhichAdirectsAtheAc
oderAtoAZ00.01A(OnAexam,AtheAproviderAindicatesAPhantomALimbAonAoccasion).AHeAhadAaA
BKA.AToAcodeAforAthisAlookAforAAbsence/leg/belowAkneeA(acquired)AwhichAdirectsAtheAcod
erAtoAZ89.51-
.WhenAreferencedAinAtheATabularAListAaAsixthAcharacterAisArequiredAforAlaterality.AThisAisAof
AtheArightAlegAwithAcorrectAcodeAZ89.511.ATheApatientAalsoAhasAdiabetes.ATheAtypeAofAdiab
etesAisAnotAdocumented.AAccordingAtoAICD-10-
CMAguideline,AI.C.4.a.2,AstatesAifAtheAtypeAofAdiabetesAmellitusAisAnotAdocumentedAinAtheA
medicalArecordAtheAdefaultAIsAE11.-
,ATypeA2AdiabetesAmellitus.ALookAinAtheAAlphabeticAIndexAforADiabetes,AdiabeticA(mellitus)A
(sugar)/typeA2AwhichAdirectsAtheAcoderAtoAE11.9.ATheA-ACORRECTAANSWERSA-
2.ADATEA04/01/20xxAMedicalAOfficeAExamADOBA03/01/XXXX
BP:A128/70;ALeftAarm.APulse:A60,ARegular.ATemperature:A98A.6AF,AOral.AHT:A5'4.5".AWT:16
9Albs.
Respirations:A16.
BMI:A28A.59Akg/m2
SmokingAstatus:ANever
Subjective:AThisA67Ayear-
oldAmaleApresentsAforAcomprehensiveAmedicalAexamination.ALivesAwithAnoAone.
InterimAproblemsAsinceAlastAvisit:ANone
ReviewAofASystems:
Constitutional:ANegative
Eyes:ANegative
Ears,ANose,AMouth,AThroat:ANegative
Cardiovascular:ANegative
Respiratory:ANegative
Gastrointestinal:ANegative
Genitourinary:ANegative
Musculoskeletal:ANegative
SkinAandA/orAbreasts:ANegative:
Neurological:ANegative
Psychiatric:ANegative
Endocrine:ANegative
Hematologic/Lymphatic:ANegative
, Allergy/AImmunologic:ANegative
PastAMedicalAHistory:
HTN
NIDDM
PastASurgicalAHistory:
LeftAShoulderARotatorACuffARepairAatAageAxx
RightARotatorACuffARepairAatAageAxx
LeftABunionectomyAandAHammertoeARepairAthreeAyearsAago
CurrentAMedications:
Rx:AASPIRINAECA81MAGA1ATABAonceAdaily,Adays,A30,ARef:A11
Rx:AATENOLOL.A50MAGA1ATABAonceAdaily,Adays,A80,ARef:A4
RxALOTENSINAHCTA20-25MGA1ATABAdaily,Adays,A80,ARef:A11
Rx:ANORVASCA10AMGA1ATABAdaily,Adays,A90,ARef:A4
Rx:AGLUCOPHAGEA500MGA1ATABATID,Adays,A180:ARef:A5
Rx:AVIAGRAA100MGA½-1AtabAPRIORATOAINTERCOURSEAPRAI,Adays,A6A,ARef:A3
Allergies:ANKDA
SocialAHistory:
Tobacco:ANo
Alcohol:AYes
Caffeine:AYes
MaritalAstatus:ASingle
Occupation:AEquipmentAOperator
FamilyAHistory:
DiabetesAMellitusAandAAlzheimer's
Objective:
General:AWellAappearing,AwellAnourished,AinAnoAacuteAdistress,Aoriented,AnormalAmoodAan
dAaffect.
Skin:AGoodAturgor,AnoArashAorAprominentAlesions
Hair·ANormalAtextureAandAdistribution.
Nails:ANormalAcolor,AnoAdeformities
Head:ANormocephalic,Aatraumatic.
Eyes:AConjunctivaAclear,AscleraAnon-ischemia,AEOMAintact,APERRL
Ears:AEAC'sAclear,ATM'sAtranslucent,AossiclesAnormalAappearance
Nose:ANoAext
ANS:
J20.9,AI10,AM80.88XD,AE78.5,AJ30.9,AZ87.891
Rationale:AInAthisAcaseAtheApatientAhasAbronchitis,Ahypertension,Ahyperlipidemia,AallergicAr
hinitis,AandAGERD.ALookAinAtheAAlphabeticAIndexAforABronchitis/acuteAwhichAdirectsAtheAco
derAtoAJ20.9;AHypertensionAwhichAdirectsAtheAcoderAtoAI10;AHyperlipidemiaAwhichAdirectsAt
heAcoderAtoAE78.5;ARhinitis/allergicAwhichAdirectsAtheAcoderAtoAJ30.9.ATheApatientAhasAost
eoporosisAwithAcompressionAfracture.ALookAinAtheAAlphabeticAIndexAforAOsteoporosis/with
AcurrentApathologicalAfracture/vertebraAwhichAdirectsAtheAcoderAtoAM80.88-
.AWhenAyouAreferenceAthisAcodeAinAtheATabularAListAaAseventhAcharacterAisArequiredAtoAide
ntifyAepisodeAofAcare.AThisApatientAisAnotAreceivingAactiveAtreatmentAforAtheAfractureAsoAthe
AsubsequentAencounterAwouldAbeAused.ATheAcorrectAcodeAwouldAbeAM80.88XD.ALastly,Ath
ANSWERS LATEST REVIEW
ANS:
N18.6,AI12.0,AE10.22,AE10.40,AE10.319,AZ99.2,AI70.209,AE78.00,AM81.0,AZ94.0,AZ94.83
Rationale:AInAthisAexampleAtheApatientAhasAhypertensionAandAendAstageArenalAdisease.AAc
cordingAtoAtheAICD-10-
CMAguidelineAI.C.9.a.2,AAssignAcodesAfromAcategoryAI12,AHypertensiveAchronicAkidneyAdi
sease,AwhenAbothAhypertensionAandAaAconditionAclassifiableAtoAcategoryAN18,AChronicAkid
neyAdiseaseA(CKD),AareApresent.AICD-10-CMApresumesAaAcause-and-
effectArelationship.AToAlocateAthisAcode,AlookAinAtheAAlphabeticAIndexAforAHypertension/wit
h/kidney/with/stageA5AchronicAkidneyAdiseaseA(CKD)AorAendAstageArenalAdiseaseA(ESRD)A
I12.0.AThereAisAanAinstructionalAnoteAthatAstatesAtoA"UseAadditionalAcodeAtoAidentifyAtheAsta
geAofAchronicAkidneyAdiseaseA(N18.5,AN18.6).AInAthisAcaseAtheApatientAhasAendAstageArena
lAdiseaseAsoAN18.6AisAassigned.ATheApatientAisAalsoAaAtypeA1AdiabeticAwithAdiabeticAretinop
athyAandAdiabeticAneuropathy.ACombinationAcodesA-ACORRECTAANSWERSA-
1.ATRANSPLANTASURGERY
Mr.AXAisAaA66Ayear-
oldAwhiteAmaleAwhoAhadAendAstageArenalAdiseaseAandAtypeAIAdiabetesAmellitusAandAunder
wentAcombinedAkidneyAandApancreasAtransplantation.AHeAlostAhisArenalAallograftAfromABKA
viralAnephropathyAandAunderwentAretransplantationAtenAyearsAago.AHeAhadAproblemsAwith
ArenalAallograftAdysfunctionAandAunderwentApercutaneousArenalAallograftAbiopsyAelevenAye
arsAago,AwhichArevealedAhypertensiveAchangesAwithinAhisAkidney.AHeArecentlyAhadAhisAlisi
noprilAdiscontinued.
HisAbloodApressuresAagainAclimbedAtoAanAunacceptableAlevel.AHeAhadAatenololAadded.AHe
AstatesAthatAhisApulseAhasAslowedAdownAwithAtheAatenolol.AHeAhasAhadAnoAtroubleAwithAdiz
ziness.AHeAbringsAhisAbloodApressureAcuffAwithAhimAtoday.AHisAcuffAreadsA170/90.AMyAread
ingAwithAtheAelectronicAcuffAisA173/84.AIAamAunableAtoAauscultateAaApressureAinAthisApatient
.AHisAlogAofAhisAbloodApressureAreadingsAatAhomeAinAtheAstandingApositionAareAusuallyAinAth
eA130Arange.AIAfeelAthatAthisAisAanAacceptableAbloodApressureAforAthisApatient.AWeAwillAaddA
noAadditionalAantihypertensiveAmedicines.
LABORATORYAREVIEWA(xx/xx/20xx)
SodiumA144;ApotassiumA5.0;AchlorideA109;AcarbonAdioxideA20;AwhiteAcount
7000;AhematocritA31.9;AplateletAcountA264,000;ABUNA43;AcreatinineA1.82;
PrografAlevelA6.4;AamylaseA28;AlipaseA69.
ASSESSMENT:
1.AHypertensionA-AreasonablyAcontrolled.
2.AEndAstageArenalAdisease.AOnAdialysis.
3.ADiabetesAmellitusAtypeAI.
4.ADiabeticAretinopathyA-Astable.
5.ADiabeticAneuropathy.
6.ABKAallograftAnephropathy.
,7.ARenalAallograftArejectionA-AJuneA1999.
8.AHypercholesterolemia.
9.AAtherosclerosis,Aextremities.
10.AOsteoporosis.
PLAN:
TheApatientAisAtoAcontinueAonAtheAcurrentAantihypertensiveAregimen.AWeAwillAscheduleAhim
AforAaAboneAdensitometryAstudyAonAhisAreturn.AHeAisAprovidedAthreeAcardsAforAstoolAsampli
ngAforAguaiacAtesting.AHeAisAtoAgetAaAbloodAcheck
ANS:
Z00.01,AZ89.511,AE11.9,AI10,AG54.6,AZ68.28,AZ79.82,AZ82.0,AZ83.3,AZ79.84
Rationale:AInAthisAcase,AtheApatientApresentsAforAaAcomprehensiveAmedicalAexamination.A
LookAinAtheAAlphabeticAIndexAforAExamination/withAabnormalAfindingsAwhichAdirectsAtheAc
oderAtoAZ00.01A(OnAexam,AtheAproviderAindicatesAPhantomALimbAonAoccasion).AHeAhadAaA
BKA.AToAcodeAforAthisAlookAforAAbsence/leg/belowAkneeA(acquired)AwhichAdirectsAtheAcod
erAtoAZ89.51-
.WhenAreferencedAinAtheATabularAListAaAsixthAcharacterAisArequiredAforAlaterality.AThisAisAof
AtheArightAlegAwithAcorrectAcodeAZ89.511.ATheApatientAalsoAhasAdiabetes.ATheAtypeAofAdiab
etesAisAnotAdocumented.AAccordingAtoAICD-10-
CMAguideline,AI.C.4.a.2,AstatesAifAtheAtypeAofAdiabetesAmellitusAisAnotAdocumentedAinAtheA
medicalArecordAtheAdefaultAIsAE11.-
,ATypeA2AdiabetesAmellitus.ALookAinAtheAAlphabeticAIndexAforADiabetes,AdiabeticA(mellitus)A
(sugar)/typeA2AwhichAdirectsAtheAcoderAtoAE11.9.ATheA-ACORRECTAANSWERSA-
2.ADATEA04/01/20xxAMedicalAOfficeAExamADOBA03/01/XXXX
BP:A128/70;ALeftAarm.APulse:A60,ARegular.ATemperature:A98A.6AF,AOral.AHT:A5'4.5".AWT:16
9Albs.
Respirations:A16.
BMI:A28A.59Akg/m2
SmokingAstatus:ANever
Subjective:AThisA67Ayear-
oldAmaleApresentsAforAcomprehensiveAmedicalAexamination.ALivesAwithAnoAone.
InterimAproblemsAsinceAlastAvisit:ANone
ReviewAofASystems:
Constitutional:ANegative
Eyes:ANegative
Ears,ANose,AMouth,AThroat:ANegative
Cardiovascular:ANegative
Respiratory:ANegative
Gastrointestinal:ANegative
Genitourinary:ANegative
Musculoskeletal:ANegative
SkinAandA/orAbreasts:ANegative:
Neurological:ANegative
Psychiatric:ANegative
Endocrine:ANegative
Hematologic/Lymphatic:ANegative
, Allergy/AImmunologic:ANegative
PastAMedicalAHistory:
HTN
NIDDM
PastASurgicalAHistory:
LeftAShoulderARotatorACuffARepairAatAageAxx
RightARotatorACuffARepairAatAageAxx
LeftABunionectomyAandAHammertoeARepairAthreeAyearsAago
CurrentAMedications:
Rx:AASPIRINAECA81MAGA1ATABAonceAdaily,Adays,A30,ARef:A11
Rx:AATENOLOL.A50MAGA1ATABAonceAdaily,Adays,A80,ARef:A4
RxALOTENSINAHCTA20-25MGA1ATABAdaily,Adays,A80,ARef:A11
Rx:ANORVASCA10AMGA1ATABAdaily,Adays,A90,ARef:A4
Rx:AGLUCOPHAGEA500MGA1ATABATID,Adays,A180:ARef:A5
Rx:AVIAGRAA100MGA½-1AtabAPRIORATOAINTERCOURSEAPRAI,Adays,A6A,ARef:A3
Allergies:ANKDA
SocialAHistory:
Tobacco:ANo
Alcohol:AYes
Caffeine:AYes
MaritalAstatus:ASingle
Occupation:AEquipmentAOperator
FamilyAHistory:
DiabetesAMellitusAandAAlzheimer's
Objective:
General:AWellAappearing,AwellAnourished,AinAnoAacuteAdistress,Aoriented,AnormalAmoodAan
dAaffect.
Skin:AGoodAturgor,AnoArashAorAprominentAlesions
Hair·ANormalAtextureAandAdistribution.
Nails:ANormalAcolor,AnoAdeformities
Head:ANormocephalic,Aatraumatic.
Eyes:AConjunctivaAclear,AscleraAnon-ischemia,AEOMAintact,APERRL
Ears:AEAC'sAclear,ATM'sAtranslucent,AossiclesAnormalAappearance
Nose:ANoAext
ANS:
J20.9,AI10,AM80.88XD,AE78.5,AJ30.9,AZ87.891
Rationale:AInAthisAcaseAtheApatientAhasAbronchitis,Ahypertension,Ahyperlipidemia,AallergicAr
hinitis,AandAGERD.ALookAinAtheAAlphabeticAIndexAforABronchitis/acuteAwhichAdirectsAtheAco
derAtoAJ20.9;AHypertensionAwhichAdirectsAtheAcoderAtoAI10;AHyperlipidemiaAwhichAdirectsAt
heAcoderAtoAE78.5;ARhinitis/allergicAwhichAdirectsAtheAcoderAtoAJ30.9.ATheApatientAhasAost
eoporosisAwithAcompressionAfracture.ALookAinAtheAAlphabeticAIndexAforAOsteoporosis/with
AcurrentApathologicalAfracture/vertebraAwhichAdirectsAtheAcoderAtoAM80.88-
.AWhenAyouAreferenceAthisAcodeAinAtheATabularAListAaAseventhAcharacterAisArequiredAtoAide
ntifyAepisodeAofAcare.AThisApatientAisAnotAreceivingAactiveAtreatmentAforAtheAfractureAsoAthe
AsubsequentAencounterAwouldAbeAused.ATheAcorrectAcodeAwouldAbeAM80.88XD.ALastly,Ath
