Solutions
01/01/XX S: Here to follow up on her atrial fibrillation. No new
problems. Feeling well. Medications are reviewed and consistent
with the medications that she was discharged home. O: BP:
110/64. Pulse is regular at 72. Neck is supple. Chest is clear.
Cardiac normal sinus rhythm. A: Chronic atrial fibrillation,
currently stable. P: 1. Prothrombin time. 2. Follow up with
myself in 1 month, sooner as needed if has any other problems
in the meantime. Will also check a creatinine and potassium
today as well. Electronically Signed: M, Jones, M.D. Based on
the review of the medical record, what discrepancy would a
coder identify?
A. The list of medications was not documented which would
affect coding
B. The provider did not document the chief complaint
C. The provider did not properly sign the documentation
D. There are no discrepancies with this documentation Correct
Answers A. The list of medications was not documented which
would affect coding
01/01/XX SUBJECTIVE: CC: This 43 year-old Caucasian male
is here today for a follow-up visit. The patient's past medical
history is notable for diabetes, hypertension, and mixed
hyperlipidemia. HPI: Patient presents with type 2 diabetes.
Specifically, this is type 2, non-insulin requiring diabetes
without complications. Compliance with treatment has been
good. In regard to the essential hypertension, benign, this was
first diagnosed several years ago. He is tolerating the medication
well without side effects. Concerning mixed hyperlipidemia,
,compliance with treatment has been good; he takes his
medication as directed, maintains his low cholesterol diet,
follows up as directed, and maintains his exercise regimen.
ROS: CONSTITUTIONAL: Negative for chills, fatigue, fever
and night sweats. CARDIOVASCULAR: Negative for chest
pain, claudication, dizziness, palpitations and pedal edema.
RESPIRATORY: Negative for dyspnea, he Correct Answers
C. There is conflicting information regarding whether the patient
is being treated with insulin
05/01/XX
EMERGENCY DEPARTMENT VISIT NOTE
Mode of arrival: The patient arrived via ambulance. The
patient's condition upon arrival was fair.
Time seen by clinician: 1558
CC. GI bleed
HPI: The patient is a 79 year-old female with COPD, CHF,
dementia and malnutrition who was transferred from a local
nursing home for evaluation of GI bleed. The patient is a poor
historian and not able to provide any history. EMS and nursing
home staff reported that the patient started with diarrhea today,
after having a "explosive" episode of diarrhea had a large
amount of bright red blood per rectum. This occurred twice prior
to arrival. On arrival to emergency department the patient was
noted to have a bleeding external hemorrhoid A Rhino rocket
was used to apply pressure to this hemorrhoid and gauze
packing with hemostasis. Approximately one hour after initial
evaluation the patient then had a more significant approximately
800 cc b Correct Answers C. K92.2, R03.1, K64.4, J44.9,
I50.9, F03.90, E46
,70 year-old with COPD is admitted to the hospital for acute
exacerbation of chronic bronchial asthma. What diagnosis
code(s) should be reported?
A. J44.1
B. J45.901, J44.9
C. J45.901
D. J44.1, J45.901 Correct Answers D. J44.1, J45.901
73 year-old visits his primary care physician to discuss lap band
procedure for his morbid obesity. His BMI is currently 45. What
ICD-10-CM code(s) should be reported?
A. E66.9
B. E66.01, Z68.42
C. E66.1, Z68.42
D. Z68.42, E66.01 Correct Answers B. E66.01, Z68.42
89 year-old female with history of PE on Coumadin presents to
cardiology for follow up. Two years ago the patient had chest
pain and a small pulmonary embolus in the right lower lobe was
found. The patient reports no symptoms and daughter says she is
at baseline. The provider documents "chronic pulmonary
embolism, continue with Coumadin". Select the diagnosis
code(s).
A. I26.09
B. I26.90
C. I27.1
D. I27.82, Z79.01 Correct Answers D. I27.82, Z79.01
A 32 year-old patient suffered a crush and avulsion type injury
which has now resulted in loss of the fourth and fifth digits at
, the metacarpophalangeal joint levels, loss of the index and long
fingers through the proximal phalanx proximal aspect and soft
tissue loss dorsally over the left hand.
What is (are) the appropriate diagnosis code(s)?
A. S63.261A, S63.263A, S67.191A, S67.193A
B. M20.092
C. Z89.022, S63.261A, S63.263A
D. M20.092, S67.191A, S67.193A Correct Answers B.
M20.092
A 45 year-old female patient presents to her primary care office
complaining of crying and overall unhappiness and sadness. The
physician has seen this patient before for the same condition and
has diagnosed the patient with Major Depressive Disorder,
Recurrent. Which of the following ICD-10-CM codes is for
Major Depressive Disorder, Recurrent?
A. F32.1
B. F33.9
C. F43.21
D. F32.9 Correct Answers B. F33.9
A 62 year-old female with a long standing history of endocrine
disease has noticed numbness in her hands and feet. She sees her
physician and after examination, her provider documents the
following:
A/P: Polyneuropathy, due to endocrine disease. Will get new
labs and have patient return in four weeks.
Assign the correct ICD-10-CM code(s) for this encounter.
A. E34.9
B. G63
C. G63, E34.9