Hiatal hernia with reflux esophagitis icd 10

Advanced Medical Coding Scenarios

Research project number (38166400)

Part 1

Review each of the following medical coding scenarios. Assign the ICD-10-CM codes for the diagnoses indicated in each scenario. Also assign the ICD-10-PCS code if any procedures are performed, unless otherwise indicated.

1. A 61-year-old female patient is seen for a complaint of severe heartburn, lightheadedness, skin reddening, and shortness of breath. The physician renders a diagnosis of GERD, sickle cell anemia, lymphangitis, and diaphragmatic paralysis. What code(s) should be assigned?

ICD-10: K21.9, D57, I89.1, J98.6 Comment by Joyce, Barbara: -1Incorrect I-10 code missing digit D57._

2. A 37-year-old patient comes in complaining of swollen joints and headaches. The physician’s diagnosis is SLE. The patient also has rheumatoid arthritis and asthma with status asthmaticus. What code(s) are assigned?

ICD-10: M32.9, M06.80, J45.902 Comment by Joyce, Barbara: -3.5Incorrect I-10 code digits M32._ _ / M06._

3. A 52-year-old patient is seen for mouth pain, knee pain, and fluid buildup in the chest. The physician renders a diagnosis of pulp degeneration, old disruption of the posterior cruciate ligament, and pleural effusion. The physician also performed a chest tube insertion (draining the right pleural cavity with a drainage device using a percutaneous approach) prior to diagnosing the patient’s pleural effusion. What diagnosis and procedure code(s) are assigned?

ICD-10: K04.2, M23.50, 0W9930Z, J90

4. A 30-year-old male is admitted to the hospital with lymphadenitis, acute lymphoid leukemia in relapse, and von Willebrand disease. What code(s) are reported?

ICD-10: I88.9, C91.02, D68.0

5. A 47-year-old male is involved in a motor vehicle accident. He was driving on the highway when his car collided with another vehicle. He was brought to the hospital with a lower arm injury. The physician obtained an x-ray of the arm and, after careful review and interpretation of the x-ray, rendered a diagnosis of lower arm fracture. The physician repaired the arm fracture using open reduction and internal fixation (reposition of the right radius with internal fixation using a percutaneous endoscopic approach). What diagnosis and procedure code(s) are reported?

ICD-10: S52.91XA, 0XQD4ZZ Comment by Joyce, Barbara: -4Missing two other I-10 codesIncorrect I-10 procedure code digits 0_ _ _4_Z

Part 2

Review each of the following medical coding scenarios. Assign the CPT code for the services and procedures indicated in each scenario.

1. A 48-year-old male patient comes to the emergency room with complaints of GERD. The physician performs a laparoscopic fundoplasty with a Collis gastroplasty. What CPT code(s) should be assigned? CPT: 43280, +43338 Comment by Joyce, Barbara: -2.5One incorrect cpt code digits 43_ _ _

2. A 40-year-old female patient is diagnosed with cervical cancer. She also complains about difficulty breathing. She is admitted to the hospital, where the physician begins to perform a bronchoscopy after anesthesia administration. However, the procedure is discontinued due to unforeseen complications. Later the same day, a bilateral cervical lymphadenectomy is performed to address the patient’s cervical cancer. What CPT code(s) are assigned?

CPT: __31635 -74, 38720 -50 Comment by Joyce, Barbara: -2.5One incorrect cpt code digit with incorrect modifier316_ _ - _ _

3. A 50-year-old patient is admitted for a repair of a laceration to the diaphragm resulting from an accident involving a bus that ran into a ditch. She also received eight trigger point injections into the transverse abdominus muscle due to pain resulting from the accident. What CPT code(s) are assigned? CPT: 39501 , 20552

4. A 23-year-old patient comes to the emergency room after being physically assaulted by her boyfriend. She complains of nasal pain and bleeding from the left nostril. The physician obtains an x-ray of the nasal cavity, and the x-ray confirms a nasal septum fracture. The physician performs an open treatment of the nasal fracture with a concomitant open treatment of the fractured septum. What CPT code(s) should be assigned?

CPT: 21335

5. A 33-year-old patient is seen in the emergency room due to complaints of headaches and congestion. The final diagnosis is maxillary sinus infection. The physician performs a nasal endoscopy with a maxillary antrostomy. She also removes some tissue from the maxillary sinus. What CPT code(s) should be assigned?

CPT: 31267

Part 3

Review each of the following medical coding scenarios. Assign the HCPCS code(s) required for each coding scenario. 1. A 49-year-old patient is admitted to the hospital for repair of an ankle fracture. On the day of discharge, the physician prescribes a dynamic ankle extension and flexion device with a soft interface material. The ankle device is adjustable. What HCPCS code(s) are assigned?

HCPCS: E1815

2. A 26-year-old patient was admitted to the hospital with acute exacerbation of allergic asthma. During the course of the hospitalization, the patient received 5 mg of omalizumab administered subcutaneously. What HCPCS code(s) are assigned?

HCPCS: J2357

3. A 58-year-old patient is admitted to the hospital due to severe anemia. He receives six units of fresh frozen plasma on the first day of admission. What HCPCS code(s) should be assigned?

HCPCS: Comment by Joyce, Barbara: -5incomplete

4. A 26-year-old patient comes to the emergency room complaining of watery diarrhea for five days. She receives 25 mcg of octreotide acetate administered intravenously. What HCPCS code(s) are assigned? HCPCS: J2354

5. A patient is brought to the emergency room after ingesting a bottle of verapamil as a suicide attempt. The physician ordered 10mg of glucagon HCL to be administered as an antidote mixed in 100 ml of D5W in an IV over 2 minutes. What HCPCS code(s) should be assigned?

HCPCS: J1610

Part 4

Review the following medical coding scenario. Assign all of the ICD-10 and CPT codes for the diagnoses and procedures indicated in the scenario. After being evaluated by his gastroenterologist, Mr. Jackson was sent to the hospital for a diagnostic esophagogastroduodenoscopy. He is having several symptoms that indicate a potential gastrointestinal condition. As a result, he was admitted in observation. His symptoms include vomiting, weight loss, and dysphagia. The esophagogastroduodenoscopy reveals that the patient has low-grade Barrett’s esophagus, GERD with reflux esophagitis and a non-obstructing hiatal hernia. Patient was also incidentally diagnosed with Crest Syndrome (CRST), which correlates with his complaint of dysphagia. After the procedure, the patient was noted to have several PVC’s on his EKG. These resolved shortly after the patient arrived in the recovery room. Based on the results of the detailed history, detailed, exam, and straight forward medical decision making, it was decided that the patient could be discharged home on the same day with instructions for a follow up office appointment in 2 days. Code this scenario.

ICD-10: ___ODJ08ZZ_________________________________________________

CPT: ______43233-43270______________________________________________ Comment by Joyce, Barbara: -25Highlighted codes and/or digits are incorrectMissing five I-10 codesMissing one E/M code with modifierIncorrect cpt code digit 4323_