instructions: Review each case study and select the correct ICD-10-CM diagnostic code. Please be aware that when an answer consists of more than one code, there will be an answer blank for each code.
Case 6
Emergency Department Visit
A 59-year-old male presented to the ED with dyspnea on exertion, fevers, and cough. A routine chest x-ray was completed to rule out pneumonia. The x-ray revealed a mass in the left lung. The patient was instructed to follow up with Dr. Ram in oncology.
Diagnosis: Probable neoplastic lung disease
ICD-10-CM Code Assignment…….x……..
Case 7
Inpatient Admission
A 40-year-old female was admitted with severe abdominal pain. She has a history of cervical cancer that was excised 4 years ago. An MRI showed possible metastasis to the left ovary, which was confirmed during this admission as ovarian carcinoma, malignant secondary site.
ICD-10-CM Code Assignment……x……. , ……x…….
Case 8
Inpatient Admission
This 89-year-old female patient was transferred from a nursing home due to a suspected urinary bladder mass, after she underwent a series of diagnostic tests that concluded that she has malignant primary adenocarcinoma of the posterior wall of the urinary bladder. She has requested no treatment and was discharged to hospice care.
ICD-10-CM Code Assignment……x…….
Case 9
Office Visit Note
This 65-year-old female patient will return to the office today for follow-up for her breast cancer. The cancer was treated three years ago, via a bilateral mastectomy, and at this time, she is showing no signs of recurrence or metastasis. Vital signs as recorded by nurse.
Heart: Normal rate and rhythm
Lungs: Clear
Abdomen: Soft, nontender, no masses
Assessment: status post mastectomy, no recurrence at this time.
Plan: Follow-up in 6 months.
ICD-10-CM Coding Assignment……x…… ,……x……..
Case 10
Office Note
This 35-year-old female patient is being seen today because she has been experiencing abdominal pain for the last month. She is concerned because her mother died of stomach cancer when she was 40 years old.
Vitals: B/P 120/75 Weight: 165 pounds.
The patient reports no weight loss.
HEENT: Normal
Heart: Normal rate and rhythm
Lungs: Clear, no rales.
Abdomen: No masses, no hepatomegaly or splenomegaly noted. Bowel sounds normal.
Breast: Symmetrical, no masses noted.
Plan: Orders as written for diagnostic testing.
The patient should follow up with me following test results.
ICD-10-CM Coding Assignment…….x…... ,…..x………