Case Study 1
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
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 – Q12.0
Overall Feedback:
Q12.0: index>cataract>congenital
Case Study 2
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
Case Study 3
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
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 – Yes
If so does the Use additional code note apply to the case study – No
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 – 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
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