QUIZ 7
George McKeown, a 65-year-old male, presents with pain around his
right eye and sensitivity to bright light. Dr. Zabawa notes redness of
the eye and sagging skin around the lower eyelid. George is
diagnosed with entropion of the right eye, lower eyelid……H02.002
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 – Entropion
What is the anatomical site – Eye
What is the laterality – Right
Do any of the following apply to the condition – Lower eyelid
Do any of the following apply to the condition – Unspecified
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 – 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 – H02.002
Overall Feedback:
H02.002: Entropion>right>lower
Rosa Fuller, a 24-year-old female, presents with ear pain. Dr. Rider
documents a thick greyish-white matter. After a thorough
examination, Rosa is diagnosed with diffuse otomycosis, external
ear.
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 – Otomycosis
What is the location – external
Do any of the following apply to the condition – None of these
Is there a manifestation code - Yes
Begin to code the encounter
Did you verify the code in the Tabular List of Diseases and Injuries - Yes
Is there an Includes notation - Yes
If so does the Includes note help to clarify – Yes
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
,Did you code to the highest level of specificity - Yes
What is the correct diagnosis code – B36.9
What is the manifestation code – H62.40
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 – Otitis
What is the location – Externa
In – Mycosis NEC
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 – Yes
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 - 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 – H62.40
Overall Feedback:
B36.9: Otomycosis
H62.40: Otitis>externa>in>mycosis NEC
John Di Toma, a 10-month-old male, was diagnosed with congenital
bilateral cataracts several weeks ago. John is admitted today for the
surgical removal of the cataracts.
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 – Cataract
Do any of the following apply to the condition – Congential
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
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
,Latoya Simpkins, a 36-year-old female, presents with the complaint
of right ear pain. Dr. Herauf also documents a low-grade fever,
cough, and nasal drainage. Dr. Herauf completes an examination
with otoscope, which visualizes a cloudy bulging eardrum with
blisters. Latoya is diagnosed with bullous myringitis.
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 – Myringitis
Do any of the following apply to the condition – Acute
What type – Bullous
What is the laterality - Right
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 – 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 – H73.011
Overall Feedback:
H73.011: Myringitis>acute>bullous>right
PATIENT: OLDENBERG, KYLE
ACCOUNT/EHR #: OLDEKY001
DATE: 10/17/18
Attending Physician: Renee O. Bracker, MD
Kyle Oldenberg, 65-year-old male, presents today with the complaints of
gradual loss of vision OD of a 2-month duration. Kyle states it doesn’t hurt,
“just getting to where I can’t see.” Kyle saw his ophthalmologist and was
diagnosed with angle closure glaucoma and was referred to us for treatment.
PMH: Healthy, no medications
FH: Noncontributory with no history of glaucoma
SH: Drinks alcohol socially and denies use of tobacco.
Eye Exam:
Best corrected visual acuities: 20/20 OS, barely hand motion vision OD.
Pupils: >2.9 LU RAPD OD
, Dx: Pseudoexfoliation glaucoma, moderate stage
P: Selective laser trabeculoplasty (ALT or SLT).
ROB/pw D: 10/17/18 09:50:16 T: 10/19/18 12:55:01
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 – Glaucoma
What type – Open angle
Do any of the following apply to the condition - Primary
Do any of the following apply to the condition – Capsular
What it the laterality – Right
What stage - Moderate
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
Is there a Code first notation - No
Is there a Code also notation – No
Is there a Use additional code notation – No
Is there an Excludes1 notation – Yes
Is there an Excludes2 notation - Yes
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 – H40.1412
Overall Feedback:
H40.1412: Glaucoma>open angle>primary>capsular>right>moderate stage
PATIENT: SEQUEN, EUGENE
ACCOUNT/EHR #: SEQUEU001
DATE: 09/16/18
Attending Physician: Oscar R. Prader, MD
Patient is a 49-year-old male diagnosed with chronic acid reflux. Barium
swallow fluoroscopy, esophageal pH probe, esophageal manometry, and
esophagoscopy were completed. He presents today to discuss the results of
those tests.
I explain that the test results indicate that he has GERD. The first course of
treatment is to adopt a lowfat, high-fiber diet. The second course would be
surgical repair. Patient was instructed not to eat at least 2 hours before going
to bed, and the head of the bed should be elevated 6 to 8 inches while in
supine position.
Patient was informed that surgery may be necessary if diet and positioning
do not relieve symptoms.
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 – Reflux
George McKeown, a 65-year-old male, presents with pain around his
right eye and sensitivity to bright light. Dr. Zabawa notes redness of
the eye and sagging skin around the lower eyelid. George is
diagnosed with entropion of the right eye, lower eyelid……H02.002
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 – Entropion
What is the anatomical site – Eye
What is the laterality – Right
Do any of the following apply to the condition – Lower eyelid
Do any of the following apply to the condition – Unspecified
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 – 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 – H02.002
Overall Feedback:
H02.002: Entropion>right>lower
Rosa Fuller, a 24-year-old female, presents with ear pain. Dr. Rider
documents a thick greyish-white matter. After a thorough
examination, Rosa is diagnosed with diffuse otomycosis, external
ear.
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 – Otomycosis
What is the location – external
Do any of the following apply to the condition – None of these
Is there a manifestation code - Yes
Begin to code the encounter
Did you verify the code in the Tabular List of Diseases and Injuries - Yes
Is there an Includes notation - Yes
If so does the Includes note help to clarify – Yes
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
,Did you code to the highest level of specificity - Yes
What is the correct diagnosis code – B36.9
What is the manifestation code – H62.40
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 – Otitis
What is the location – Externa
In – Mycosis NEC
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 – Yes
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 - 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 – H62.40
Overall Feedback:
B36.9: Otomycosis
H62.40: Otitis>externa>in>mycosis NEC
John Di Toma, a 10-month-old male, was diagnosed with congenital
bilateral cataracts several weeks ago. John is admitted today for the
surgical removal of the cataracts.
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 – Cataract
Do any of the following apply to the condition – Congential
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
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
,Latoya Simpkins, a 36-year-old female, presents with the complaint
of right ear pain. Dr. Herauf also documents a low-grade fever,
cough, and nasal drainage. Dr. Herauf completes an examination
with otoscope, which visualizes a cloudy bulging eardrum with
blisters. Latoya is diagnosed with bullous myringitis.
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 – Myringitis
Do any of the following apply to the condition – Acute
What type – Bullous
What is the laterality - Right
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 – 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 – H73.011
Overall Feedback:
H73.011: Myringitis>acute>bullous>right
PATIENT: OLDENBERG, KYLE
ACCOUNT/EHR #: OLDEKY001
DATE: 10/17/18
Attending Physician: Renee O. Bracker, MD
Kyle Oldenberg, 65-year-old male, presents today with the complaints of
gradual loss of vision OD of a 2-month duration. Kyle states it doesn’t hurt,
“just getting to where I can’t see.” Kyle saw his ophthalmologist and was
diagnosed with angle closure glaucoma and was referred to us for treatment.
PMH: Healthy, no medications
FH: Noncontributory with no history of glaucoma
SH: Drinks alcohol socially and denies use of tobacco.
Eye Exam:
Best corrected visual acuities: 20/20 OS, barely hand motion vision OD.
Pupils: >2.9 LU RAPD OD
, Dx: Pseudoexfoliation glaucoma, moderate stage
P: Selective laser trabeculoplasty (ALT or SLT).
ROB/pw D: 10/17/18 09:50:16 T: 10/19/18 12:55:01
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 – Glaucoma
What type – Open angle
Do any of the following apply to the condition - Primary
Do any of the following apply to the condition – Capsular
What it the laterality – Right
What stage - Moderate
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
Is there a Code first notation - No
Is there a Code also notation – No
Is there a Use additional code notation – No
Is there an Excludes1 notation – Yes
Is there an Excludes2 notation - Yes
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 – H40.1412
Overall Feedback:
H40.1412: Glaucoma>open angle>primary>capsular>right>moderate stage
PATIENT: SEQUEN, EUGENE
ACCOUNT/EHR #: SEQUEU001
DATE: 09/16/18
Attending Physician: Oscar R. Prader, MD
Patient is a 49-year-old male diagnosed with chronic acid reflux. Barium
swallow fluoroscopy, esophageal pH probe, esophageal manometry, and
esophagoscopy were completed. He presents today to discuss the results of
those tests.
I explain that the test results indicate that he has GERD. The first course of
treatment is to adopt a lowfat, high-fiber diet. The second course would be
surgical repair. Patient was instructed not to eat at least 2 hours before going
to bed, and the head of the bed should be elevated 6 to 8 inches while in
supine position.
Patient was informed that surgery may be necessary if diet and positioning
do not relieve symptoms.
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 – Reflux
