Tricia Thornwell, a 68-year-old female, was going If so does the Code also note apply to the case
walking when she fell down the icy front steps of study? No Code also note
her house; now she can't bear weight on her
right leg. She is brought into the ER by Is there a Use additional code notation? Yes
ambulance. After the ER physician completed a
thorough exam and reviewed the x-ray, he If so does the Use additional code note apply to
diagnosed her with a femoral neck base fracture, the case study? No
nondisplaced. - -Principal diagnosis
Is there an Excludes1 notation? Yes
Where should you begin to look up the code in
the coding manual? Index to Diseases and If so does the Excludes1 note apply to the case
Injuries study? No
What is the key term? Fracture Is there an Excludes2 notation? Yes
What type? Traumatic If so does the Excludes2 note apply to the case
study? No
What is the anatomical site? Femur
Is there a symbol indicating additional characters
What is the location? Upper end, neck are required? Yes
Do any of the following apply to the condition? Do you need to use the placeholder "X"? No
Nondisplaced
Did you code to the highest level of specificity?
What is the laterality? Right Yes
Do any of the following apply to the condition? What is the correct diagnosis code? S72.044A
Initial encounter
***Second diagnosis***
Begin to code the encounter.
Where should you begin to look up the code in
Did you verify the code in the Tabular List of the coding manual? External cause of injuries
Diseases and Injuries? Yes index
Is there an Includes notation? No What is the key term? Fall from
If so does the Includes note help to clarify? No What? Stairs
Includes note
Due to? Ice and snow
Is there a Code first notation? No Do any of the following apply to the condition?
Initial encounter
If so does the Code first note apply to the case Begin to code the encounter.
study? No Code first note
Did you verify the code in the Tabular List of
Is there a Code also notation? No Diseases and Injuries? Yes
, Chp 16 Coding Practice Questions and Answers
Is there an Includes notation? Yes - -What is the principal diagnosis code?
If so does the Includes note help to clarify? Yes S90.32XA
Is there a Code first notation? No What is the second diagnosis code?
If so does W22.03XA
WESTON HOSPITAL Helen Carrizo, an 18-year-old female, presents to
629 Healthcare Way • SOMEWHERE, FL 32811 the ED with a painful left ankle. Helen is
• 407-555-6541 accompanied by her mother. Helen had been
PATIENT: TRUMAN, HERBERT rollerblading and tripped, falling on the sidewalk.
ACCOUNT/EHR #: TRUMHE001 Helen is unable to flex her ankle, which has
DATE: 07/16/22 begun to swell. Dr. Webber gathered a brief
Attending Physician: Oscar R. Prader, MD history of the incident that caused the injury, as
S: Pt is a 47-year-old male brought in by well as any history relating to her legs and feet.
ambulance accompanied by his wife. Wife states He then performed a limited examination of her
he has been confused, dizzy, and vomiting all left leg, ankle, and foot. The imaging confirmed a
morning. sprained calcaneofibular ligament and a sprained
O: Ht. 5′11″, Wt. 187 lb., R 16. During the anterior tibiofibular ligament. - -Principal
physical examination, the patient has a dramatic diagnosis
drop in vital sign measurements and suffers
cardiac arrest. The crash team takes over and Where should you begin to look up the code in
patient is successfully resuscitated. Blood work the coding manual? Index to Diseases and
reveals overdose of digoxin. After Pt is stabilized, Injuries
he states he was rushing to get to work this
morning and couldn't remember if he had taken What is the key term? Sprain
his medication, so he took it again.
A: Cardiac arrest due to overdose of digoxin, What is the anatomical site? Ankle
accidental
P: Admit for stabilization What is the location? Calcaneofibular ligament
Oxygenation
Hydration IV fluids What is the laterality? Left
Monitor electrolyte balance - -
T46.0X1AI46.9 Do any of the following apply to the condition?
Initial encounter
Patricia Neil, a 34-year-old female, presents Begin to code the encounter.
today with a painful left foot. Patricia accidentally
hit her foot on a desk this morning and is Did you verify the code in the Tabular List of
concerned she might have broken it. Dr. Diseases and Injuries? Yes
Dickerson examines Patricia's foot and notes
swelling and discoloration. Dr. Dickerson orders Is there an Includes notation? Yes
an x-ray, which confirms no fractures. Patricia is
diagnosed with a contusion, bruise harm score 1. If so does the Includes note help to clarify? Yes