Question 11 pts Code the following using

Question 11 pts Code the following using ICD-10-CM Ambulatory Surgery Center A 16-year-old patient developed a nodule in the left lobe of the thyroid. the clinical working diagnosis was autoimmune thyroiditis. Ultrasound of the thyroid revealed a hypoechoic nodule, and thyroid function tests were within normal limits. Fine-needle aspiration was nondiagnostic, left thyroid lobectomy was performed, and pathology report revealed a diagnosis of dyshormonogenic goiter. Flag question: Question 2Question 21 pts Code the following using ICD-10-CM Ambulatory Surgery Center Patient is a 5-year-old white male with history of right undescended testicle since birth. He is scheduled at this time for right orchiopexy. Physical Exam: Lung clear. Heart regular; 3/6 systolic murmur heard best at the right sternal border. Abdomen soft. No CVA tenderness. Genital examination showed a circumcised penis. Testis was down on the left side, an the right testis was in the area of the external ring. Laboratory values: Hemoglobin 13.5. Normal differential. Urinalysis unremarkable. Chest x-ray normal. Patient was admitted to the short stay unit and on the day of admission underwent right inguinal herniorrhaphy and right orchiopexy. Postoperatively, the patient did well. There were o apparent anesthesia complications, and he was discharged to home the afternoon after surgery. Diagnoses: Right inguinal hernia and right abdominal cryptorchidism. Flag question: Question 3Question 31 pts Code the following using ICD-10-CM Ambulatory Surgery Center The 63-year-old white male was seen with chief complaint of large right indirect inguinal hernia, which is easily reduced but has been painful and is getting larger. Physical Examination: Large right indirect inguinal hernia easily reduced. Also noted 1+benign prostatic hypertrophy. The patient was prepared for surgery; under satisfactory general anesthesia, a right indirect inguinal hernia was repaired and a lipoma of the spermatic cord removed. Following the operation, he had an uncomplicated postoperative recovery. He was awake and alert, and he had no anesthetic complications. He is released to see Dr. Smith in one week and me in two weeks or immediately if there is any evidence of wound infection. Flag question: Question 4Question 41 pts Code the following using ICD-10-CM Ambulatory Surgery Center atient is a 40-year-old white female who in June had a sudden exacerbation of right upper quadrant and midepigastric pain radiating around both subcostal margins to the back. She saw Dr. Cosby, who ordered the appropriate studies; the patient was found to have acute cholecystitis. Within a very short period of time, she proceeded to get right lower quadrant pain. Just before she was due to see me in the office about her gallbladder, I saw her in the emergency room with right lower quadrant pain. She had acute appendicitis. She had an appendectomy at that time, and she has done fairly well during the three months or so since then. But recently she began to have abdominal pain intermittently; on five occasions within a week prior to admission, she began having severe pain and could hardly eat anything at all. She had no evidence of jaundice or hepatitis. The pain would last several hours at times, and she had not been able to eat anything well. I saw her, And we proceeded to make arrangements for cholecystectomy and operative cholangiography. She did not take any mediation regularly at the time of admission. Past medical history reveals that she had an appendectomy, no other surgery, no known medical illnesses or drug allergies. She did have wisdom teeth removed in the past. At the time of surgery, she’s a well-developed, well-nourished white female in no apparent distress. Vital signs are stable; she was afebrile and in no pain at that time. Physical examination: revealed, other than an obese abdominal wall, that the abdominal exam was unremarkable. The rest of the physical exam was consistent with age, and body habitus was generally within normal limits. Chest x-ray was normal. EKG showed no acute changes. CBC was normal. She was taken to the operating room, where she was under antibiotic prophylaxis. Cholecystectomy and operative cholangiography were done. Diagnoses: Chronic cholecystitis, quite symptomatic, with acute cholecystitis Flag question: Question 5Question 51 pts Code the following using ICD-10-CM Ambulatory Surgery Center The patient is a 46-yer-old white male who was seen in the office on December 19. At that time, he was complaining of a nodule on both testicles, which he had seen for two months. He stated they were initially felt to be a cyst of the tunica albuginea of the testicle. He was reassured at that time and instructed to return in six weeks. When he returned for a follow-up visit, it was thought that this area had increased in size and was nontender. But in view of the fact that it had been changed in size, I thought that we should explore him to biopsy and remove this area. The possibility of a testicular tumor was also considered. Physical examination was remarkable only for o.5-cm nodule, which extended off the surface of the testicle near the lateral aspect of the head of the epididymis on the right side. The left testicle felt normal. Laboratory Values: Chest x-ray was normal. Urinalysis showed 0-1 white cells. The patient was admitted the morning of surgery, and under general endotracheal anesthesia had a right inguinal exploration with removal of what then became apparent as a metacystic epididymis with a small spermatocele. The upper third of the epididymis was removed along with the spermatocele. Postoperatively, the patient did well, tolerated adequate diet, and was discharged in good condition. Diagnosis: Right spermatocele, multiple cysts. Flag question: Question 6Question 61 pts Chiropractic Office: Code the following using ICD-10-CM Mr. Davis, a 52 -year-old CPA, presents with a complaint of neck and right shoulder pain accompanied with frequent right arm numbness of three weeks’ duration following a busy tax season. Physical examination procedures lead to a diagnosis of thoracic outlet syndrome. Treatment consists of chiropractic manipulation treatment and therapeutic stretching of the cervical and thoracic region. Flag question: Question 7Question 71 pts Chiropractic Office: Code the following using ICD-10-CM Mr. Clark, a 61-year-old farmer, presents with a complaint of right gluteal pain with pain radiating down his right leg posteriorly of one-day duration following prolonged operation of a tractor. Physical examination procedures confirm diagnosis of sciatica. Treatment consisted of chiropractic manipulative treatment of the sacral region and electrical stimulation application. Flag question: Question 8Question 81 pts Chiropractic Office: Code the following using ICD-10-CM Cheryl Miller, a 12-year-old female, presents with a complaint of low back pain following a gymnastic recital one day prior. Physical examination procedures lead to a diagnosis of myalgia, neck. Treatment consists of chiropractic manipulative treatment and traction of the lumbar spine. Flag question: Question 9Question 91 pts Chiropractic Office: Code the following using ICD-10-CM Ms. Greeley, a 45-year-old author, presents with a complaint of generalized neck pain of one week’s duration after several days of long hours at her computer. Physical examination procedures lead to a diagnosis of myalgia, neck. Treatment consists of chiropractic manipulation treatment and massage of the cervical region. Flag question: Question 10Question 101 pts Chiropractic Office: Code the following using ICD-10-CM Ms. Thomas, a 27-year-old receptionist, presents with a complaint of neck pain with muscle spasms after sneezing tow hours prior. Physical examination procedures confirm a diagnosis of cervical neck strain. Treatment consists of chiropractic manipulative treatment and application of ultrasound to the cervical region (initial encounter). Flag question: Question 11Question 111 pts Hospital Emergency Department: Code the following using ICD-10-CM Patient referred to me by Dr. Brown on 9/19. Dr. Brown had seen the patient twice as a outpatient for problems with swallowing and pain and discomfort in his throat. She believed there was a problem in the throat, possibly a strep pharyngitis. The patient came to the hospital ED, arriving at 166 on 9/19. Shortly thereafter, I interviewed the patient. During the course of the interview, it became apparent that his symptoms were those of esophageal obstruction; I quickly arranged for him to go to the radiology department for a barium swallow, which was perplexing in that there appeared to be an obstruction of an unusual type.. The radiologist was called in and evaluated the obstruction, and then we talked with Dr. Ardell concerning the apparent lesion. Dr. Ardell thought the lesion was too high for him to do gastroscopy safely. For this reason, they suggested and I concurred that we refer him to an ear, nose, and throat specialist at the county clinic. The patient was in full agreement with this. No laboratory studies were done at this time. His respirations were 20, blood pressure 120/66, weigh t178, all recorded by the nurses. Diagnosis: Esophageal obstruction Flag question: Question 12Question 121 pts Hospital Emergency Department: Code the following using ICD-10-CM The patient was examined in the ED and found to have a large fungating, pigmented lesion 2 cm in diameter over the left temporal area near the ear. With the patient in a supine position and his head rotated to the right, the left side of his face and head were prepared with pHisoHex and draped with sterile drapes. Marcaine anesthesia 0.5% solution was infiltrated in the skin and subcutaneous tissues about the lesion, and about 5cc of solution was used. Then the lesion was excised by elliptical incision, trying to stay in normal skin and taking the subcutaneous tissues with it. Bleeding point were ligated with 4-0 Prolene suture in a vertical mattress type of suture. The wound was prepared with pHisoHex. Following this, the patient withstood the procedure well and returned home awake and in good condition. He has been instructed to return immediately if there is any evidence of infection such as excessive pain, tenderness, redness, swelling, bleeding, discharge, red streaks, or fever. Otherwise, he should see me in about 9 or 10 days for removal of the sutures. Diagnosis: Pigmented lesion, skin of left temporal area near the ear (2cm). Flag question: Question 13Question 131 pts Hospital Emergency Department: Code the following using ICD-10-CM A 31-year-old male was seen in the ED for pain and swelling of his right middle finger. He had been working with some PVC pipe and had a fragment of it enter his finger just over the PIP joint. He was seen in the ED at that time and had the fragment extracted under local anesthesia. The wound pulled was approximately 3/8 inches long. Overnight the finger became very swollen and sore, and the patient returns to the ED this evening for subsequent care. X-ray reveals no apparent injury to the bony structures. There is no apparent abscess present. The wound is not draining, although the finger is red and very tender. Assessment: Infection of puncture wound, right middle finger. Plan: Keflex 500 milligrams 4 x daily, warm soaks to the finger (if possible 4x daily), and rechecked in 24 hours. (Subsequent encounter). Flag question: Question 14Question 141 pts Hospital Emergency Department: Code the following using ICD-10-CM This 81-year-old female presented to the ED with a complaint of right foot pain. The patient stated that she bumped the foot one month ago, and ever since then she has had intermittent pain in the right great toe. Physical exam of the right foot reveals that the patient has a significant bunion over the first metatarsal head. The patient is tender minimally in this area. There is some redness, but no significant warmth to touch. The patient has full range of motion of the toe, with moderate pain. X-ray of the first great toe of the right foot reveals no fractures. Diagnosis: Right foot pain. Sprain of the right great toe versus early gout. Treatment: Uric acid level was drawn; this was 6.6, which was within the normal range. Because of the patient’s physical findings, I did not think that it would be appropriate to tap her joint at this time. I will start her on Motrin 600 milligrams 3 times daily, and she will see Dr. Thomas in five days. The patient was instructed that if the pain worsens or does not show some improvement before she can see Dr. Thomas, she should return to the emergency department, at which time further evaluation and possible tapping or the joint will be undertaken. Flag question: Question 15Question 151 pts Hospital Outpatient Department: Code the following using ICD-10-CM A 31-year-old male patient previously diagnosed with end-stage renal disease(ESRD) and diabetic nephropathy due to type 1 diabetes mellitus and aggravated by chronic alcoholism undergoes scheduled dialysis. The dialysis technician starts dialysis. It soon becomes apparent that the patient is drunk because after just 20 minutes of dialysis treatment, the patient becomes belligerent, yanks out the needles, and leaves the hospital. Diagnoses: End-stage renal disease. Diabetic nephropathy due to type 1 diabetes mellitus. Chronic alcoholism. Flag question: Question 16Question 161 pts Hospital Outpatient Department: Code the following using ICD-10-CM A 59-year-old woman who presents to the outpatient pain clinic has suffered from the occurrence of severe headache each week for the past 35 years. Upon assessment, it is determined that the headaches are cervicogenic in origin. Cephalic cervical nerve bloc was administered, and the patient was scheduled to return for a follow-up visit in 30 days. She was also instructed to call if the headaches recurred before her scheduled visit. Diagnosis: Recurrent headaches. Flag question: Question 17Question 171 pts Hospital Outpatient Department: Code the following using ICD-10-CM Patient seen in the outpatient clinic for suspected cholecystitis. The patient reports right upper quadrant (RUQ) abdominal pain. Family history is positive for cholecystitis with cholelithiasis and cholecystectomy. Laboratory work reveals mild hyperglycemia, which apparently has been under control with oral antidiabetic agents. Chest X-ray is negative. Blood tests revealed that bilirubin is essentially negative, but there is a slight elevated alkaline phosphatase. Blood chemistry tests indicate that sodium, CO2, and chloride results are somewhat depressed. Potassium is normal. Ultrasound of gallbladder reveals significant hypertrophy. Diagnoses: Hypertrophy of gallbladder. Right upper quadrant abdominal pain. Mild hyperglycemia. Abnormal blood chemistry levels. Probable cholecystitis. Flag question: Question 18Question 181 pts Hospital Outpatient Department: Code the following using ICD-10-CM This 18-month-old male with a past history of having undergone elective repair of right inguinal hernia and right hydrocele presents for evaluation of possible left-sided strabismus. Surgical wound is healing nicely, and the patient is experiencing no complaints related to the surgery. The patient was cleared by the surgeon las weeks in his office. The patient’s medical history reveals an uncomplicated medical history and surgical history. He has no known allergies or illnesses. He has had an appropriate development. It is noted today that he does have strabismus, which has not been previously evaluated by an ophthalmologist. All immunizations by history have been up-to-date. There is no appreciable family or social history that is contributory. Physical exam reveals appropriate growth and development for this 18-month-old male. His left-sided strabismus is noted. Ears were clear bilaterally with some cerumen retained, but tympanic membranes were observed. Nasal septum midline. Posterior pharynx is noninjected. Neck is supple without lymphadenopathy. Lungs auscultated clear to base. Cardiac was RRR without S3, S4, or murmurs auscultated. The abdomen was soft without organomegaly or masses. Patient was circumcised. Patient is referred to Dr. Allen, Ophthalmologist, for evaluation of strabismus. Diagnosis: Strabismus, left eye Flag question: Question 19Question 191 pts Hospital Outpatient Department: Code the following using ICD-10-CM This 5-year-old child is seen for evaluation of temperature of 103 degrees F, which has lasted three days and has not been controlled by Tylenol or Motrin. The lungs are clear. The neck is no longer rigid. the pharynx is slightly injected. Strep test performed, and results are pending lab evaluation. Spinal tap L3 and L4 performed without difficulty. The fluid is crystal clear an dis sent to the lab. Lab results were negative. Diagnoses: Elevated temperature. Sore throat. Possible strep throat. Flag question: Question 20Question 201 pts Hospital Same Day Surgery: Code the following using ICD-10-CM The patient was admitted with gross hematuria following a long duration of prostatic symptoms and intermittent hematuria for several days. After the insertion of the Foley catheter and drainage of 400cc of grossly bloody Urine, chemistry tests revealed that he was in chronic renal insufficiency with a BUN of 66. His urinary output was very adequate.; IVP showed poorly functioning kidneys but enough also to show an elevation of the bladder floor consistent with enlarged prostate benign. Cystoscopy was carried out to rule out other causes of hematuria and the bladder found to be heavily trabeculated with many diverticuli and again a large prostatic gland. Diagnoses: Chronic renal insufficiency. Bladder diverticula. Benign prostatic hypertrophy Flag question: Question 21Question 211 pts Hospital Same Day Surgery: Code the following using ICD-10-CM This is a 15-yer-old who was involved in a truck and bicycle accident in August. He continued to have problems with his right knee. He was referred to Dr. Jones, who diagnosed him as having torn medial meniscus of right knee as the sequela of previous fracture right patella and knee soft tissue injuries. Patient was admitted to the hospital on August 17 and underwent surgery that consisted of arthrotomy and medial meniscectomy of right knee. Patient did well on a postoperative period and was sent home in good condition. Diagnosis: Bucket-handle tear of medial meniscus, right knee. (Sequela) Flag question: Question 22Question 221 pts Hospital Same Day Surgery: Code the following using ICD-10-CM Two weeks ago on routine examination, Dr. Woughter detected a firm ridge in the right lobe of the prostate, became suspicious, and suggested to the patient that he have this biopsied at an early date. Patient presents now for biopsy procedure. A needle biopsy of the prostate reveals adenocarcinoma of the prostate. Pathology results report adenocarcinoma of prostate. I have advised a radical prostatectomy. Diagnosis: Carcinoma of the prostate. Flag question: Question 23Question 231 pts Hospital Same Day Surgery: Code the following using ICD-10-CM: Physician Office This 27-year-old male was working in his workshop, making a toy for his daughter, when he accidently punctured his left fourth finger with a drift pin. The patient states that the pin entered from the radial aspect and existed through the the ulnar aspect of the finger. Physical exam reveals a puncture wound through and through on the pad of the left ring finger. X-ray of the finger shoes no evidence of involvement of the bone. The patient was given a tetanus-diphtheria booster. The wound was debrided and cleaned with Betadine, and Betadine ointment was placed over the wound. Diagnosis: Puncture wound, left ring finger. Plan: The patient was instructed to soak the finger with half hydrogen peroxide and half water three or four times a day for four to five days; he is to return immediately if any sings of infection appears. (Initial Encounter) Code for External Cause Codes as well Flag question: Question 24Question 241 pts Hospital Same Day Surgery: Code the following using ICD-10-CM Physician Office: This man was participating in a softball tournament this weekend. He has had brief episodes of dizziness off an on for about a week, which last for 20 minutes and occur once a day. He is dizzy at this time; at other times, his left ear feels plugged up. No history of any injury or trauma. His vitals are stable. Neurological exam is completely unremarkable. No evidence of any other symptomatology, such as chest pain. He has no carotid bruits. ENT: Okay. Neck: Supple, no nodes or thyroid abnormalities. Chest: Peripheral lung fields are clear. Heart sounds are good. Eyes: Disc margins are sharp. No evidence of any increased pressure. His BP was 120.80. Romberg negative. He is steady on his feet. His left ear is slightly dull, and I suspect that he has low-grade serous otitis media. I started him on Pen-Vee K 500 mg 4 times daily along with 1 Actifed tablet 4 times daily with the understanding that if he has any incrase4 in symptoms or any persistence of symptoms beyond two or three days, he is to be rechecked by his family physician at home. If that were to be the case, he would need a central nervous system workup. Diagnosis: Low-grade serous otitis media, left. Flag question: Question 25Question 251 pts Hospital Same Day Surgery: Code the following using ICD-10-CM Physician Office: This young man walked into a tree limb while setting traps last week, and he lacerated the left cornea. I could see no hyphema when he came in for an office visit at that time, but the anterior chamber may have been affected. He returns for an office visit threes later because he has blurred vision, and I could not see well into the eye when he was treated during his last visit. He is now being referred to Dr. Andrews for further and more definitive evaluation and treatment. Diagnosis: Laceration, left cornea. Blurred vision. (Subsequent encounter). Flag question: Question 26Question 261 pts Hospital Same Day Surgery: Code the following using ICD-10-CM Physician Office: This young lady came to the office due to laryngitis and quite a cough. Chest X-ray did not show any specific consolidation, but I suspect bronchitis. She had a white count of 10,300. Hgb was 13.5gm%; she had 71 segs, 18 lymphs, 7 monos, 1 eosinophil, and 3 band cells. She is being started on 500mg of V0Cillin-K four times daily for one day and then 250mg 4 times daily for eight days along with Phenergan expectorant. She is to return to her family physician in four to six days for follow-up care. Diagnosis: Bronchitis Flag question: Question 27Question 271 pts Hospital Same Day Surgery: Code the following using ICD-10-CM Physician Office: This young lady apparently did something to inure her right hip approximately two weeks prior to her arrival in the office. When she arrived here, she was ambulatory but had some soreness in the lateral surface of the hip. Range of motion of the leg and hip are perfectly okay. She has no neurological deficit of either leg. Deep tendon reflexes were equal and active, no sensory loss; no low back pain as such. X-ray were taken of the lumbar spine and hip and reported as normal. She is being treated symptomatically with warm soaks, Equagesic 2 every 6 hours, and recheck in the office in three or four days. Diagnosis: Spain, right hip and ligaments of lumbar spine. (initial encounter) Flag question: Question 28Question 281 pts Hospital Same Day Surgery: Code the following using ICD-10-CM Stand-Alone Radiology Center A patient is referred to the radiology center for magnetic resonance imaging (MRT) due to complaints of severe back pain. M  

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