COMPLETE WITH INSTRUCTIONS
Note that the following question requires additional access to APC grouper software.
Instructions: Provide the most correct responses.
Question
A 60-year-old female presented to the hospital outpatient surgical unit for repair of an umbilical hernia, which was performed via an open approach in Operating Room B. The patient had minimal blood loss and was sent to the recovery room in good condition. The patient was discharged home later that same day.
a. Assign the ICD-10-CM code(s) to the first-listed diagnosis. FILL IN BLANK WITH CODE
b. Assign the CPT code(s) to the procedure(s). FILL IN BLANK WITH CODE
c. Enter the patient’s CPT procedure code(s) in APC grouper software. Review the APC grouper results and answer the following question: To which APC does this patient group belong? FILL IN BLANK WITH CODE
A 55-year-old male presented to the hospital outpatient surgical unit for a cystoscopy. The patient’s complaint was hematuria. A transurethral diagnostic cystoscopy was performed. No acute or abnormal findings were determined to be the cause of his hematuria. The patient was sent to the recovery room in good condition and was discharged later that same day.
a. Assign the ICD-10-CM code(s) to the first-listed diagnosis. FILL IN BLANK WITH CODE
b. Assign the CPT code(s) to the procedure(s). FILL IN BLANK CODE
c. Enter the patient’s CPT code(s) in APC grouper software. Review the APC grouper results and answer the following question: To which APC does this patient group belong? FILL IN BLANK CODE
45-year-old female complained of fatigue and underwent a laboratory blood test that revealed elevated T3 and T4 levels. The patient underwent a fine-needle aspiration biopsy of her thyroid as an outpatient. The patient experienced minimal blood loss and was discharged home at the conclusion of the procedure.
a. Assign the ICD-10-CM code(s) to the first-listed diagnosis and the additional diagnosis. FILL IN BLANK, FILL IN BLANK
b. Assign the CPT code(s) to the procedure(s). FILL IN BLANK
c. Enter the patient’s CPT code(s) in APC grouper software. Review the APC grouper results and answer the following question: To which APC does this patient group belong? FILL IN BLANK
An 80-year-old male patient presented to the hospital outpatient surgical unit for the removal of a cortical senile cataract from his left eye. The patient underwent an extracapsular cataract extraction with anterior chamber intraocular lens (IOL) implant insertion. There were no problems, and the patient was sent to the recovery room in good condition. He was later discharged home to be followed in the office.
a. Assign the ICD-10-CM code(s) to the first-listed diagnosis. FILL IN BLANK
b. Assign the CPT and HCPCS level II code(s) to the procedure(s). FILL IN BLANK
c. Enter the patient’s CPT and HCPCS level II code(s) in APC grouper software. Review the APC grouper results and answer the following question: To which APC does this patient group belong? FILL IN BLANK
.
Question
A 67-year-old female underwent a laparoscopic cholecystectomy for cholelithiasis with acute cholecystitis. The patient also had an intraoperative cholangiogram performed. The patient had minimal blood loss and was discharged home later that day.
a. Assign the ICD-10-CM code(s) to the first-listed diagnosis and the additional diagnoses. FILL IN BLANK
b. Assign the CPT code(s) to the procedure(s). FILL IN BLANK
c. Enter the patient’s CPT procedure code(s) in APC grouper software. Review the APC grouper results and answer the following question: To which APC does this patient group belong? FILL IN BLANK
A 75-year-old female patient is admitted directly to the hospital with the complaint of severe dyspnea. She has a history of hypertensive renal disease and diabetes mellitus controlled with insulin. Upon examination, she is noted to have edema on her legs and feet. Radiographic films indicate fluid in her lungs. Her albumin level is .5 grams per decaliter, and her creatinine level is 3.0 milligrams per decaliter. Sputum culture is positive for Klebsiella pneumoniae. Her blood pressure upon admission is 155/100. She is diagnosed with acute left ventricular heart failure, acute exacerbation of hypertensive renal disease, and pneumonia due to Klebsiella pneumoniae. Antihypertensive medications, antibiotics, insulin, Zocor, and intravenous diuretics are administered, and her diet is restricted for sodium and fluid. Three days later, she is discharged home in an improved condition.
DISCHARGE DIAGNOSES: Acute left ventricular heart failure. Hypertensive heart and renal disease, stage 2. Pneumonia due to Klebsiella pneumoniae. Hyperlipidemia. Type 2 diabetes mellitus.
a. Assign ICD-10-CM codes to the principal diagnosis of congestive heart failure and comorbidities.
(No procedures were performed.)
a. Principal diagnosis code: FILL IN BLANK
b. Enter the patient’s age, gender, discharge status, and all applicable ICD-10-CM and ICD-10-PCS codes in the DRG grouper software. Review the DRG grouper results and answer the following questions:
What is the MDC number? FILL IN BLANK
c. What is the DRG number and description? FILL IN BLANK
66-year-old man with a history of cerebrovascular accident who is seen in the emergency department for complaints of chest pain and oral phase dysphagia. He is noted to have a temperature of 101 degrees upon examination. He is admitted as a hospital inpatient for further evaluation and treatment. Has a history of type 2 diabetes mellitus and hypertension. Lab tests include a white blood cell count with differential and a chest X-ray. Results reveal that Mr. Browne has pneumonia, and a sputum culture is ordered. The sputum culture results are negative. A percutaneous endoscopic gastrostomy (PEG tube) is inserted to assist with his nutrition, which is difficult due to his dysphagia. He is administered respiratory therapy for the pneumonia. His feeding is done via the PEG tube. His oral antihypertensive and diabetic medications are continued as an inpatient. After several days he is discharged to a skilled nursing facility for further care.
FINAL DIAGNOSES: Viral pneumonia. Oral phase dysphagia due to previous cerebrovascular accident
(CVA). Type 2 diabetes mellitus. Hypertension.
PROCEDURE: Insertion of percutaneous endoscopic gastrostomy (PEG tube).
Question
Assign the principal ICD-10-CM diagnosis code.FILL IN BLANK
A patient is admitted through the emergency department (ED) with the chief complaint of nosebleeds. The patient also complains of facial pain on the right side of her face and head. Patient is a 67-year-old female with a history of diabetes mellitus, hypertension (HTN), and epistaxis 10 years ago (status postcauterization) who has presented to the ED twice in the last five hours for right nasal epistaxis. Positive profuse bleeding is noted at times. During the first visit at 10:50 p.m., the patient was administered Neo-Synephrine drops and sent home. During the second visit at 4 a.m., the right nostril was packed with gauze soaked in lidocaine with epinephrine, and the patient’s bleeding resolved. Right epistaxis was treated with balloon therapy and at present is under control. Patient was admitted for further treatment and consultation with the ear, nose, and throat specialist. Patient was administered Xanax 0.25 mg by mouth for anxiety, Dilaudid 0.5 mg intravenously every three hours as needed for facial pain, and prophylactic Cleocin 600 mg intravenously every eight hours. The first dose was at 4:40 a.m. today. Her hypertension was treated with Lasix 20 mg and Tenormin 50 mg by mouth daily. For her hyperlipidemia, she received Zocor 10 mg by mouth daily. She received Diabinese 100 mg daily for her type 2 diabetes mellitus. The patient then underwent endoscopic control of right epistaxis with cautery done for her condition. Postoperatively, her red blood cell count, hemoglobin, and hematocrit were low. She was diagnosed with blood-loss anemia and received 2 units of packed red blood cells (nonautologous) via peripheral vein. She was discharged on day 4 of this admission with an order for home health services.
FINAL DIAGNOSES: Epistaxis. Acute posthemorrhagic anemia. Type 2 diabetes mellitus. Hypertension.
Hyperlipidemia.
PROCEDURES: Endoscopic control of right epistaxis with cautery. Transfusion with packed red blood cells.
Question
Assign the principal ICD-10-CM diagnosis code.FILL IN BLANK
A 45-year-old female is admitted to the hospital with the chief complaint of severe left arm pain. This patient has a history of end stage renal failure, and she has an arteriovenous graft in her left arm for dialysis access. The patient’s end stage renal failure is due to hypertensive renal disease. She receives dialysis on Tuesday, Thursday, and Saturday. The patient was seen, evaluated, and scheduled for surgery. Postoperative diagnosis was end stage renal failure with left upper extremity arteriovenous graft stenosis. Procedures performed are fluoroscopy of dialysis fistula (high osmolar), left upper extremity, and declotting of arteriovenous graft, left upper extremity with percutaneous infusion of urokinase. Postprocedurally, the patient had a run of sinus tachycardia that was treated with medication. Postprocedurally, her blood pressure was 163/100. She was administered intravenous antihypertensive medication for this. She was discharged on day two in an improved condition with instructions to follow up with her nephrologist at the renal clinic.
FINAL DIAGNOSES: Severe left arm pain due to left upper extremity arteriovenous graft stenosis.
Hypertensive renal disease with end stage renal failure. Postprocedural sinus tachycardia.
PROCEDURES: Percutaneous declotting of arteriovenous graft, left upper extremity, with percutaneous infusion of urokinase. Fluoroscopy of dialysis fistula (high osmolar).
a. Assign ICD-10-CM codes to the principal diagnosis. FILL IN BLANK
b. Assign ICD-10-PCS codes to the principal procedure. FILL IN BLANK
c. Enter the patient’s age, gender, discharge status, and all applicable ICD-10-CM and ICD-10-PCS codes in the DRG grouper software. Review the DRG grouper results and answer the following question:
What is the DRG number? FILL IN BLANK
An 85-year-old man presents with the complaint of shortness of breath and fatigue. Both of these symptoms have become worse over the past month. The patient is an active man and works with his son and grandson in a real estate business. These symptoms are preventing him from working. His past medical history includes bypass grafting 12 years ago. The patient is admitted for further workup and treatment. Diagnostic testing reveals that the patient has aortic valve stenosis. This is confirmed by catheterization. A right and left cardiac catheterization confirms that the patient’s previous bypass graft is working well. Surgery for aortic valve replacement with synthetic substitute is performed. Postoperatively, the patient’s gout was exacerbated in his right foot. He does have a history of this condition. Oral medication is given to treat the gout, and on postoperative day four, the patient is discharged home in an improved condition.
FINAL DIAGNOSES: Aortic stenosis. Previous bypass graft surgery. Gout, right foot.
PROCEDURES: Aortic valve replacement (open approach). Right and left cardiac catheterization (percutaneous approach).
a. Assign ICD-10-CM codes to the principal diagnosis. FILL IN BLANK
b. Assign ICD-10-PCS codes to the principal procedure. FILL IN BLANK
c. Enter the patient’s age, gender, discharge status, and all applicable ICD-10-CM codes in the DRG grouper software. Review the DRG grouper results and answer the following question: What is the DRG number? FILL IN BLANK
