ICD-10-CM and CPT Coding Scenarios: Diagnoses and E/M Codes

QUESTION

Use your ICD-10-CM and CPT to determine the accurate diagnosis and procedure codes. Note: E/M codes do not apply.

23.

Scenario 1

 

Worth 4.000 points.

 

HISTORY
The patient is a 32-year-old male who presented with a red-colored, 2 cm conical-shaped nodule
on the back of his neck. He claims it grew in size within the past 24 hours. He had a boil in the
same spot 6 months ago and it required removal. Fluctuant was felt with palpation. Severe pain was
noted with slight pressure. He denies a history of diabetes mellitus or use of immunosuppressive
drugs. Due to the excessive pain and reoccurrence of this furuncle, incision and drainage was
recommended.

PROCEDURE
The patient signed the consent form and was taken to the procedure room. Using sterile technique,
the posterior neck was prepped, draped and anesthetized with 1% lidocaine. The lesion was lanced
resulting in rapid resolution and reduction of pain. Pressure was held on the site with minimal
bleeding noted. Betadine ointment was applied, and it was then covered with gauze and secured
with tape. A sample of the fluid was sent to the laboratory. The patient will return in 3-5 days for a
wound check.

ICD-10 code

CPT code

 

 

24.

Scenario 2

 

Worth 6.000 points.

 

HISTORY
The patient is a 5-year-old female who was practicing for a ballet recital. As she was completing
a pirouette, she twisted her knee and fell to the ground. To ensure that permanent damage had not
occurred, the orthopedist felt a diagnostic arthroscopy of her knee should be done.

PROCEDURE
After full explanation of the procedure, the parents signed the consent form. The patient was
escorted into the procedure room by her parents where she was sedated. The incision site was
prepped and draped. Injection of a saline solution distended the joint. The arthroscope was
advanced into the joint through a small skin incision. The exploration revealed a complex lateral
meniscus tear of the right knee. A meniscal repair was then scheduled. The arthroscope was
removed. Minimal bleeding was noted and the site was covered with sterile dressing. The patient
tolerated the procedure well and was taken to the operating room for further care.

Note: External cause code(s) apply, but external cause status is not necessary.

ICD-10 code

ICD-10 code

CPT code

 

 

25.

Scenario 3

 

Worth 4.000 points.

 

HISTORY
This very pleasant 69-year-old male suffered an embolic stroke 11 months ago. He has been in an
assisted-care facility for the past 10 months. Redness was noted in his right thigh extending to the
toes. He complains of tenderness around the area and a dull, aching pain in his leg when walking
that is not relieved with rest. There is also pain when raising his leg and flexing his foot.

PROCEDURE
Consent forms were signed, and a complete venous occlusion plethysmography of both legs was
performed. Deep vein thrombosis of the lower right extremity was noted. Further review of his chart
will determine treatment. A physical therapy consult will be ordered.

ICD-10 code

CPT code

 

 

26.

Scenario 4

 

Worth 4.000 points.

 

HISTORY
The patient is a 12-year-old female who was at softball practice when she was hit in the nose
with the softball while in the outfield. After 20 minutes, the team nurse was unable to control the
bleeding. Her father then took his daughter to the emergency department.

PROCEDURE
After being admitted and consent forms signed, the physician determined her nose is negative
for a fracture. The patient was diagnosed with epistaxis. Anterior, simple packing with gauze was
inserted into the right nostril to apply constant pressure. The patient was advised to avoid touching
or blowing her nose. The packing can be taken out slowly and gently within the next 6-8 hours. If
bleeding persists, she should return to the emergency department or contact her physician.

ICD-10 code

CPT code

 

 

27.

Scenario 5

 

Worth 10.000 points.

 

PREOPERATIVE DIAGNOSIS
Subdural hematoma.

POSTOPERATIVE DIAGNOSIS
Subdural hematoma.

PRIMARY PROCEDURE
BURR HOLE FOR EVACUATION AND DRAINAGE OF SUBDURAL HEMATOMA.

BRIEF HISTORY
The patient is a 16-year-old student. At her high school, she was standing on the top of a “human
pyramid,” lost her balance and fell on her head hitting the right side. She immediately felt drowsy
and confused. By the time the paramedics arrived, she complained of a unilateral headache on the
right side. Pupillary dilation was ipsilateral to the injured side. At the hospital, the location of the
hematoma was located by angiography followed by x-ray and a CT scan.

PROCEDURE
The consent form was signed by the parents, and the patient was taken to the operating room.
She was anesthetized, and the right frontotemporal region was prepped and draped. A burr
hole, using a rounded tip, was made into the skull. Immediate evacuation and decompression
resulted. The patient’s vitals were stable, and she was discharged to the neurosurgeon for
evaluation of a craniotomy.

Note: External cause code(s) apply.

ICD-10 code

ICD-10 code

ICD-10 code

ICD-10 code

CPT code

 

 

28.

Scenario 6

 

Worth 4.000 points.

 

PREOPERATIVE DIAGNOSIS
Rectal prolapse.

POSTOPERATIVE DIAGNOSIS
Rectal prolapse.

PRIMARY PROCEDURE
ABDOMINAL PROCTOPEXY.

PROCEDURE
The patient was taken to the operating room and placed on the table in the supine position. After the induction of anesthesia by the general endotracheal technique, bilateral lower extremity pneumatic
compression stockings were placed. A Foley catheter was placed, and a rectal tube was placed for subsequent irrigation and testing of the proctopexy procedure.

After standard prep and drape, a midline celiotomy incision was created entering into the peritoneal cavity and subsequent exploration was without discovery of any pathology with exception of extreme
laxity of the mesentery of the entire colon and a tremendous amount of redundant colon.

Attention was then directed to the rectosigmoid region where peritoneal reflections were taken down bilaterally with specific identification and protection of both ureters. The peritoneal reflection was
then divided in the caudad direction, and the rectosigmoid and rectum were mobilized from the sacral hollow utilizing a combination of sharp and blunt dissection.

Once the rectum has been freed to the level of the tip of the coccyx, it was brought up under modest tension into the operative field and reflected to the patient’s left. An inverted T-shaped
piece of Gore-Tex soft tissue patch was then fashioned and was subsequently secured to the sacral hollow up to the point of the sacral promontory utilizing a series of interrupted 0 Gore-Tex sutures.
Subsequently the rectum was placed in mild tension within the span of 2 limbs of Gore-Tex soft tissue patch and subsequently encircled by those limbs. These were each then packed at multiple
points to the rectum utilizing a series of interrupted 2-0 Prolene sutures placed in seromuscular fashion. Once the tacking procedure was done, the pelvis and retroperitoneum were irrigated with
saline and evacuated.

The rectum was then irrigated with saline placed via the rectal tube and was noted to expand easily within the confines of the noncircumferential Gore-Tex sling. The rectum was then evacuated. The midline fascia was then closed utilizing #1 Prolene suture in continuous running fashion. The subcutaneous tissue was irrigated, and the skin was closed with stainless steel clips. A sterile dressing was applied. Patient was aroused from his anesthetic, extubated in the operating room and transported to the PAR in stable condition.

ICD-10 code

CPT code

 

 

29.

Scenario 7

 

Worth 6.000 points.

 

PREOPERATIVE DIAGNOSIS
Endometrial intraepithelial neoplasia, grade III, on cervical biopsy and endocervical curettage.

POSTOPERATIVE DIAGNOSIS
Endometrial intraepithelial neoplasia, grade III, on cervical biopsy and endocervical curettage.

PRIMARY PROCEDURE
1. CONE BIOPSY.
2. ENDOCERVICAL CURETTAGE.
3. ENDOMETRIAL CURETTAGE WITH BIOPSY.

FINDINGS AND PROCEDURE
After the induction of adequate general endotracheal anesthesia, the patient was placed in the dorsal lithotomy position. Examination under anesthesia demonstrated a small cervix and uterus without any adnexal masses. The cervix was firm to palpation. The speculum demonstrated a cervix that was smooth and without lesions. Colposcopy was performed and was noted to be unsatisfactory. No lesions were seen. Cone biopsy was then performed with a sound in the cervix. This was difficult to accomplish due to the cervix being flush with the uterus. The cone biopsy was tagged at 12 o’clock. No cone tip was cut. Endocervical curettage was performed. Endometrial curettage was then performed. The uterus sounded to 4 cm, and scant tissue was obtained. Hemostasis was then assured. The Bovie was used to control any bleeding. Patient tolerated the procedure satisfactorily; however intraoperatively the patient did have an increased blood pressure that was controlled quickly with nadolol. The patient’s blood pressure then was stable at 120/60. Anesthesia: General endotracheal. Estimated blood loss: 10 mL. Intravenous fluids: 1600 mL. Lines: IV and arterial line. Urinary output during the procedure: 700 mL. Drains: None.
Count: Correct.

The specimens that were sent to pathology: (1) Cone biopsy, (2) endocervical curettage, (3) endometrial curettage. Urine was sent for cytology.

ICD-10 code

CPT code

CPT code

Use your ICD-10-CM and CPT to determine accurate diagnoses (no external cause codes apply) and E/M codes.

30.

Scenario 8

Worth 4.000 points

Bobby was playing softball when he misjudged the ball, and it hit him in the nose. He was taken to the emergency department at the hospital. Dr. Jones performed a detailed history and an expanded problem focused exam, with a moderate complexity medical decision making. Bobby was diagnosed with a nasal contusion and released.

ICD-10 code

EM code

31.

Scenario 9

Worth 4.000 points.

Franco, a new patient to the office, went to see Dr. White complaining of pain in his upper arm. He had been experiencing some muscle weakness and had difficulty getting out of the bathtub. Franco also has a rash and fever. Dr. White documents a detailed history and exam because of Franco’s past medical history of rheumatoid arthritis. The medical decision making was of moderate complexity. Dr. White diagnosed Franco with infective myositis in the upper arm.
ICD-10 code

EM code

32.

Scenario 10

Worth 4.000 points

Jerry called his doctor when he had a sudden onset of nausea, abdominal cramping and bloody diarrhea with mucus. Dr. Smart had Jerry come to the office right away, and Dr. Smart documented an expanded problem focused history and performed a detailed examination. The medical decision making was moderate complexity. Dr. Smart determined Jerry had noxious food poisoning. Jerry was sent home to rest. Dr. Smart told Jerry that the symptoms should subside within 5-7 days. Jerry was told to watch for dehydration and to call immediately if he felt he was not getting any better.

ICD-10 code

EM code

ANSWER

ICD-10-CM and CPT Coding Scenarios: Diagnoses and E/M Codes

Scenario 1

ICD-10 code: L02.411 – Cutaneous abscess of back with cellulitis
CPT code: 10060 – Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); simple or single

Scenario 2

ICD-10 code: S83.591A – Other tear of lateral meniscus, current injury, right knee, initial encounter
ICD-10 code:Z01.818 – Encounter for other preprocedural examination
CPT code:29881 – Arthroscopy, knee, surgical; with meniscectomy (medial and lateral, including any meniscal shaving) including debridement/shaving of articular cartilage (chondroplasty), same or separate compartment(s), when performed

Scenario 3

ICD-10 code: I80.209 – Phlebitis and thrombophlebitis of unspecified deep vessels of right lower extremity
CPT code: 93970 – Duplex scan of arterial inflow and venous outflow of abdominal, pelvic, scrotal contents and/or retroperitoneal organs; complete study

Scenario 4

ICD-10 code: R04.0 – Epistaxis
CPT code:30901 – Control nasal hemorrhage, anterior, simple (limited cautery and/or packing) any method

Scenario 5

ICD-10 code: S06.5X9A – Traumatic subdural hemorrhage with loss of consciousness of any duration, initial encounter
ICD-10 code: S06.5X9D – Traumatic subdural hemorrhage with loss of consciousness of any duration, subsequent encounter
ICD-10 code: S06.5X9S – Traumatic subdural hemorrhage with loss of consciousness of any duration, sequela
CPT code: 61250 – Craniotomy for evacuation of hematoma (eg, epidural, subdural, or intracerebral), supratentorial, any approach

Scenario 6

ICD-10 code: K62.5 – Rectal prolapse
CPT code:45397 – Abdominal proctopexy (eg, Delorme procedure)

Scenario 7

ICD-10 codeN85.89 – Other specified noninflammatory disorders of uterus
ICD-10 code: N86 – Erosion and ectropion of cervix
ICD-10 code:D06.9 – Carcinoma in situ of cervix, unspecified
CPT code:57520 – Conization of cervix, with or without fulguration, with or without dilation and curettage, includes removal of transformation zone; loop electrode excision
CPT code:57505 – Biopsy of cervix, single or multiple, or local excision of lesion, with or without fulguration (separate procedure)
CPT code: 58110 – Dilation and curettage, diagnostic and/or therapeutic (nonobstetrical)

Scenario 8

ICD-10 code: S00.130A – Contusion of nose, initial encounter
EM code: 99212 – Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity

Scenario 9

ICD-10 code: M60.89 – Other myositis, not elsewhere classified
EM code:99202 – Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making

Scenario 10

ICD-10 code: A05.9 – Food poisoning, bacterial, unspecified
EM code: 99213 – Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity