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
,QUIZ 7.
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
,QUIZ 7.
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
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.
, QUIZ 7.
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
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.
The benefits of buying summaries with Stuvia:
Guaranteed quality through customer reviews
Stuvia customers have reviewed more than 700,000 summaries. This how you know that you are buying the best documents.
Quick and easy check-out
You can quickly pay through credit card or Stuvia-credit for the summaries. There is no membership needed.
Focus on what matters
Your fellow students write the study notes themselves, which is why the documents are always reliable and up-to-date. This ensures you quickly get to the core!
Frequently asked questions
What do I get when I buy this document?
You get a PDF, available immediately after your purchase. The purchased document is accessible anytime, anywhere and indefinitely through your profile.
Satisfaction guarantee: how does it work?
Our satisfaction guarantee ensures that you always find a study document that suits you well. You fill out a form, and our customer service team takes care of the rest.
Who am I buying these notes from?
Stuvia is a marketplace, so you are not buying this document from us, but from seller studysolution. Stuvia facilitates payment to the seller.
Will I be stuck with a subscription?
No, you only buy these notes for $25.49. You're not tied to anything after your purchase.