Femwell ICD-10-CM Training Quiz Phase 3 GASTROENTEROLOGY

Transcription

1 Femwell ICD-10-CM Training Quiz Phase 3 GASTROENTEROLOGY Circle the best answer to each question 1. Ashley presented to the office in severe abdominal pain. After taking an appropriate history and performing an appropriate physical exam, it was determined that her abdomen was painful and rigid. Ashley was immediately sent to the hospital Emergency Department for further evaluation. The medical record indicated that Ashley had an Acute abdomen. The best ICD-10-CM diagnosis code to be assigned to this service is: A. R10.0 B. R C. R10.84 D. R19.02 Answer: The options in this case are R10.0 Acute abdomen, R Generalized abdominal tenderness, R10.84 Generalized abdominal pain, and R19.02 Left upper quadrant abdominal swelling, mass or lump. While B & C are not inherently wrong, A is best because it most closely matches the condition described in the documentation. D would be wrong because there is no mention of swelling, masses, or lumps. 2. Carolyn presented to the office with a complaint of lower left abdominal pain. Upon examination, Dr. Carson noted that the pain was rebound in nature. The patient was sent to the hospital radiology department for ultrasound. The ultrasound did not indicate any specific findings in the lower left side, but it revealed that there was an unusual finding near the retroperitoneum. She returned to the office for a follow up visit. follow up service would be: A. R10.32; R B. R C. R10.824, R93.5 D. R93.5

2 Answer: The code options in this case are R10.32 Left lower quadrant pain, R Left lower quadrant rebound tenderness, and R93.5 Abnormal findings on diagnostic imaging of other abdominal regions including retroperitoneum. It is not wrong to report the left lower quadrant pain, but R is a more precise code to report. It is also desirable to report the abnormal diagnostic imaging study, making Option C the best choice in this case. 3. Gertrude, a 48 year old patient, had a screening colonoscopy. After an unremarkable procedure, she was discharged home. Two days later, Gertrude called the office, complaining that she felt that she had a fever. She came to the office and a fever of 101.6F was confirmed. The patient had no physical findings during the encounter and no specific cause was identified during the encounter, although a trial of antibiotics was initiated. service would be: A. R50.81 B. R50.82 C. R50.9 D. R69 Answer: The code options in this case are R50.81 Fever presenting with conditions classified elsewhere, R50.82 Postprocedural fever, R50.9 Fever unspecified, and R69 Illness unspecified. Option A can only be used as a secondary diagnosis with a causal condition is reported as the primary diagnosis. The proximity of the fever to the surgery (and especially the presumptive decision to prescribe antibiotics in response to a possible infection) make Option B the best choice. Because of the information available in the record, the unspecified codes are not the best options. If the patient had reported that everyone in her home had a fever, then R50.9 might be a better option because it creates doubt that the fever is related to the procedure. 4. Following her surgery, Olivia had intense abdominal pain. Further investigation revealed that she had an intestinal obstruction, which would require surgical intervention to address. A. K91.3 B. K C. K D. K91.89

3 Answer: The code options in this case are K91.3 Postprocedural intestinal obstruction, K Postprocedural hemorrhage and hematoma of a digestive system organ or structure following a digestive system procedure, K Postprocedural hemorrhage and hematoma of a digestive system organ or structure following other procedure, and K91.89 Other postprocedural complications and disorders of digestive system. There is no mention of a hemorrhage or hematoma and it is clearly a postoperative condition, making Option A the best choice. 5. Priscilla was having a hysterectomy performed by a gynecologist. During the procedure, the bowel (colon) was lacerated. Dr. Preston, a colorectal surgeon was called in to repair the bowel laceration. The best diagnosis codes for Dr. Preston to report for this surgery are: A. S36.509A, K91.72 B. S36.509A, K91.62 C. S36.509A, K91.71 D. S36.509A, K Answer: The coding options in this case are S36.509A Unspecified injury of unspecified part of colon initial encounter, K91.72 Accidental puncture and laceration of a digestive system organ or structure during other procedure, K91.62 Intraoperative hemorrhage and hematoma of digestive system organ or structure complicating other procedure, K91.71 Accidental puncture and laceration of digestive system organ or structure complicating a digestive system procedure, and K Postprocedural hemorrhage and hematoma of a digestive system structure following a digestive system procedure. Because the exact injury is known (although the location is not), it is reported as the primary diagnosis. The secondary diagnosis is found in Option A because it was a laceration that occurred during a procedure related to a different organ system (genitourinary). 6. Harold was referred to Dr. Harrison s office with complaints of epigastric pain. After taking a history and performing an examination, and ordering some diagnostic tests, Dr. Harrison diagnosed Harold with gastroesophageal reflux disease with esophagitis. Harold has now returned to discuss the treatment options for this condition. A. K20.8 B. K21.0 C. K21.0, K20.9 D. K21.9

4 Answer: The coding options in this case are K20.8 Other esophagitis, K21.0 Gastro-esophageal reflux disease with esophagitis, K20.9, Esophagitis unspecified, and K21.9 Gastro-esophageal reflux disease without esophagitis. Option B is the best choice in this case because it matches the diagnostic statement existing in the record. Option C is not incorrect, but it is redundant and, therefore, not the best option. 7. Isabel was diagnosed with a gastric ulcer by Dr. Isaacson. According to the documentation, it was a chronic gastric ulcer, with no hemorrhage or perforation. service would be: A. K25.0 B. K25.7 C. K25.9 D. K26.7 Answer: The coding options in this case are K25.0 Acute gastric ulcer with hemorrhage, K25.7 Chronic gastric ulcer without hemorrhage or perforation, K25.9 Gastric ulcer unspecified as acute or chronic without hemorrhage or perforation, and K26.7 Chronic duodenal ulcer without hemorrhage or perforation. Since it was clearly diagnosed as a chronic ulcer without hemorrhage or perforation, Option B is the best choice. 8. Jacquelyn has suffered from ulcerative proctitis for quite some time. She presents today with additional pain and bleeding associated with the condition. Upon examination, Dr. Johnson indicates in the medical record that, in addition to the bleeding, a specific abscess is also identified. A. K51.211, K B. K51.311, K C. K D. R52 Answer: The coding options in this case are K Ulcerative (chronic) proctitis with rectal bleeding, K Ulcerative (chronic) proctitis with abscess, K Ulcerative (chronic) rectosigmoiditis with rectal bleeding, K Ulcerative (chronic) rectosigmoiditis with unspecified complications, K (invalid code), and R52 Pain unspecified. Because there are two specific conditions (bleeding and an abscess) two diagnosis codes are needed to capture the patient s condition. R52 is a code that should be avoided at almost any cost because it is so vague and non-specific. The best choice is Option A.

5 9. Kenneth has struggled with chronic constipation. Today he presents to the office with complaints of anal pain. Dr. Kayser s examination reveals an anal fissure. Dr. Kayser discusses treatment options for both the constipation and the fissure. A. K60.0 B. K60.1, K59.00 C. K60.2, K59.00 D. K60.5, K59.00 Answer: The coding choices in this case are K60.0 Acute anal fissure, K60.1 Chronic anal fissure, K59.00 Constipation unspecified, K60.2 Anal fissure unspecified, and K60.5 Anorectal fistula. While the case states that the constipation is chronic, it does not state one way or the other as to whether the fissure is chronic or acute. Therefore, the unspecified codes in both cases are the most appropriate (Option C). 10. Raymond was surgically treated last week for a third degree hemorrhoid. He is returning to the office for a postoperative examination. The best ICD-10-CM diagnosis code(s) to be assigned to this service is: A. K64.2 B. Z09 C. Z09, K64.2 D. Z08, K64.2 Answer: The coding options in this case are K64.2 Third degree hemorrhoid, Z09 Encounter for follow up examination after completed treatment for condition other than malignant neoplasm, and Z08 Encounter for follow examination of completed treatment for malignant neoplasm. Because the purpose of this encounter is a postoperative visit, the post operative code is the primary diagnosis, with the hemorrhoid as the secondary. Because the hemorrhoid is not a malignant neoplasm, Option C is the correct choice. 11. Arianna, has been seen frequently by Dr. Anderson, with ongoing complaints of irritable bowel syndrome. In taking her history, she explains that she has not had any diarrhea in the recent past. What ICD-10-CM diagnosis code should Dr. Anderson send to the payer for this encounter? A. K58

6 B. K58.0 C. K58.9 D. K59.00 Answer: The coding options in this case are K58 (invalid code), K58.0 Irritable bowel syndrome with diarrhea, K58.9 Irritable bowel syndrome without diarrhea, and K59.00 Constipation unspecified. There is no mention of constipation in this case as well as no diarrhea. Therefore, Option C is the best choice for this case. 12. Carrie has been diagnosed with a malignant neoplasm of the colon. The medical record indicates that the neoplasm exists in the splenic flexure and the descending colon. A. C18.5, C18.6 B. C18.6 C. C18.6, C18.7 D. C18.8 Answer: The coding options in this case are C18.5 Malignant neoplasm of splenic fixture, C18.6 Malignant neoplasm of descending colon, C18.7 Malignant neoplasm of sigmoid colon, and C18.8 Malignant neoplasm of overlapping sites of the colon. Because the neoplasm exists in overlapping sites, Option D is the correct option. Separate codes would be reported if malignant neoplasms were present in more than one non-overlapping site. 13. Deborah has been diagnosed with basal cell carcinoma of the skin of the anus. She is being seen today to discuss treatment options. What ICD-10-CM diagnosis code should Dr. Dennis send to the payer for this encounter? A. C43.51 B. C C. C D. C4A.51 Answer: The coding options in this case are C43.51 Malignant melanoma of anal skin, C Basal cell carcinoma of anal skin, C Other specified malignant neoplasm of anal skin, and C4A.51 Merkel cell carcinoma of anal skin. Because it is a basal cell carcinoma, Option B is the only appropriate choice.

7 14. Evelyn presents to the office today for a colonoscopy. She is very concerned because has a number of family members who were recently diagnosed with colonic polyps. A. Z12.11, Z83.71 B. Z12.11, Z83.79 C. Z80.0, Z83.71 D. Z83.71 Answer: The coding options in this case are Z12.11 Encounter for screening for malignant neoplasm of colon, Z83.71 Family history of colonic polyps, Z83.79 Family history of other diseases of the digestive system, and Z80.0 Family history of malignant neoplasm of digestive organs. The purpose of today s encounter is to screen for malignant neoplasms because of a family history of polyps. That makes Option A the appropriate choice for this case. There is no mention of other disease processes or family history of malignant neoplasms. 15. Dr. Franklin was called to the emergency room to see a patient who had experienced a construction injury at work. Because of a fall, he had experienced a rectal laceration. A. S36.61XS B. S36.63XA C. S36.63XD D. S36.69XA Answer: The coding options in this case are S36.61XS Primary blast injury of rectum sequela, S36.63XA Laceration of rectum initial encounter, S36.63XD Laceration of rectum subsequent encounter, S36.69XA Other injury of rectum. Because the precise injury is defined and the fact that it is the initial encounter, the only correct option in this case is Option B.