Fred Draper, a 39-year-old male, is HIV-positive, asymptomatic. Fred was just admitted with
organic pneumonia.
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 – Pneumonia
What type – Organic
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 - Yes
If so does the Code first note apply to the case study – No
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 – No
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 – J18.8
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 – Human
What type – Immunodeficiency virus disease
Do any of the following apply to the condition – Asymptomatic status
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 - Yes
If so does the Code first note apply to the case study – No
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 - No
,If so does the Excludes2 note apply to the case study – No Excludes2 notation
Is there a symbol indicating additional characters are required - No
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 – Z21
Overall Feedback:
J18.8: Pneumonia>specified NEC
Z21: Human>immunodeficiency virus disease>asymptomatic status
Maxine Weber, a 42-year-old female, comes in today with the complaint of severe pain in the
right side of her lower abdomen. Maxine also says she has vomited. Dr. Jefferson documents a
temperature of 101 F. Maxine is admitted to the hospital, where a CT scan confirms the
diagnosis of acute appendicitis with localized peritonitis.
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 – Appendicitis
Do any of the following apply to the condition – Acute
Do any of the following apply to the condition – Peritonitis
What type – Localized
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 – No
If so does the Excludes1 note apply to the case study – No Excludes1 notation
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 – K35.30
, Overall Feedback:
K35.30: Appendicitis>acute>with>peritonitis>localized
Jack Friedman, a 41-year-old male, was in a fight at a soccer game and was hit in the head with
a bottle, which caused some deep lacerations in his scalp. Dr. Girald performed a layered
closure of the wounds: one 2.0 cm, one 4.5 cm, and two lacerations that were 1.0 cm each in
length.
Principal Procedure:
Where should you begin to look up the code in the coding manual - CPT Alphabetic Index
What is the key term - Wound
What is the procedure - Repair
What is the anatomic site - Scalp
What type of repair - Intermediate
What is the total size of the lacerations for this anatomical group - 8.5 cm
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 - 12034
Overall Feedback:
12034: Index>wound>repair>scalp>intermediate>7.6 cm to 12.5 cm
2.0 + 4.5 + 1.0 + 1.0 = 8.5 cm
Nakeisha Dittman, a 27-year-old female, presents today with a cough, fever, shortness of
breath, and night sweats, 2 weeks duration. Dr. Mokeba completes a thorough examination and
decides to admit Nakeisha to the hospital. Further laboratory tests confirm the diagnosis of
eosinophilic pneumonia with secondary spontaneous pneumothorax.
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 –Pneumonia
organic pneumonia.
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 – Pneumonia
What type – Organic
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 - Yes
If so does the Code first note apply to the case study – No
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 – No
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 – J18.8
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 – Human
What type – Immunodeficiency virus disease
Do any of the following apply to the condition – Asymptomatic status
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 - Yes
If so does the Code first note apply to the case study – No
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 - No
,If so does the Excludes2 note apply to the case study – No Excludes2 notation
Is there a symbol indicating additional characters are required - No
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 – Z21
Overall Feedback:
J18.8: Pneumonia>specified NEC
Z21: Human>immunodeficiency virus disease>asymptomatic status
Maxine Weber, a 42-year-old female, comes in today with the complaint of severe pain in the
right side of her lower abdomen. Maxine also says she has vomited. Dr. Jefferson documents a
temperature of 101 F. Maxine is admitted to the hospital, where a CT scan confirms the
diagnosis of acute appendicitis with localized peritonitis.
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 – Appendicitis
Do any of the following apply to the condition – Acute
Do any of the following apply to the condition – Peritonitis
What type – Localized
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 – No
If so does the Excludes1 note apply to the case study – No Excludes1 notation
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 – K35.30
, Overall Feedback:
K35.30: Appendicitis>acute>with>peritonitis>localized
Jack Friedman, a 41-year-old male, was in a fight at a soccer game and was hit in the head with
a bottle, which caused some deep lacerations in his scalp. Dr. Girald performed a layered
closure of the wounds: one 2.0 cm, one 4.5 cm, and two lacerations that were 1.0 cm each in
length.
Principal Procedure:
Where should you begin to look up the code in the coding manual - CPT Alphabetic Index
What is the key term - Wound
What is the procedure - Repair
What is the anatomic site - Scalp
What type of repair - Intermediate
What is the total size of the lacerations for this anatomical group - 8.5 cm
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 - 12034
Overall Feedback:
12034: Index>wound>repair>scalp>intermediate>7.6 cm to 12.5 cm
2.0 + 4.5 + 1.0 + 1.0 = 8.5 cm
Nakeisha Dittman, a 27-year-old female, presents today with a cough, fever, shortness of
breath, and night sweats, 2 weeks duration. Dr. Mokeba completes a thorough examination and
decides to admit Nakeisha to the hospital. Further laboratory tests confirm the diagnosis of
eosinophilic pneumonia with secondary spontaneous pneumothorax.
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 –Pneumonia
