MIT Medical's Coding Corner Quiz

1. Patient with tobacco use has acute gingivitis, non-plaque induced.

K05.11, Z87.891 - Chronic gingivitis, non-plaque induced and Personal history of nicotine dependence

K05.01, Z87.891- Acute gingivitis, non-plaque induced and Personal history of nicotine dependence

K05.11, Z72.0 - Chronic gingivitis, non-plaque induced and Tobacco use

K05.01, Z72.0 - Acute gingivitis, non-plaque induced and Tobacco use

Gingivitis is acute but must be coded to the correct “non-plaque induced” type. Tobacco use must be coded, be careful not to code as tobacco dependence.

Explanation

Gingivitis is acute but must be coded to the correct “non-plaque induced” type. Tobacco use must be coded, be careful not to code as tobacco dependence.

2. Tina was treated at her doctor's office for warts on her hands.

B07.9 – viral warts unspecified

B07.8 – other viral warts

B07.0 – plantar wart

L82.1 – other seborrheic keratosis

You just look up under wart, viral

Explanation

You just look up under wart, viral

3. Tim is diagnosed today with viral gastroenteritis.

K52.9 – non-infective gastroenteritis and colitis unspecified

A08.4 – viral intestinal infection unspecified

A08.39 – other viral enteritis

K52.89 – other specified non-infective gastroenteritis and colitis

You look up under gastroenteritis, viral, NEC (not elsewhere classified)

Explanation

You look up under gastroenteritis, viral, NEC (not elsewhere classified)

4. A 79-year-old man presents with osteoporosis with a new pathological fracture of the right femur.

M81.0, M84.451A – Age related osteoporosis without current pathological fracture and pathological fracture, right femur, initial encounter for fracture

M80.051A – Age-related osteoporosis with current pathological fracture, right femur, initial encounter for fracture

M80.052A – Age related osteoporosis with current pathological fracture, left femur, initial encounter for fracture

You look up under Osteoporosis, age related with a current pathological fracture. Code is M80.051 which is important because this signifies laterality (right). The seventh character A indicate initial encounter for the fracture.

Explanation

You look up under Osteoporosis, age related with a current pathological fracture. Code is M80.051 which is important because this signifies laterality (right). The seventh character A indicate initial encounter for the fracture.

5. Patient with alcohol abuse complains of GERD

F10.10, K21.9 - Alcohol abuse, uncomplicated and Gastro-esophageal reflux disease without esophagitis

K21.0, F10.10 - Gastro-esophageal reflux disease with esophagitis and Alcohol abuse, uncomplicated

K21.9. F10.10 – Gastro-esophageal reflux disease w/o esophagitis and alcohol abuse uncomplicated

K20.9, F10.10 – Esophagitis unspecified and alcohol abuse uncomplicated

GERD is coded to gastro-esophageal reflux disease without esophagitis which is a .9 code because it is not specified with esophagitis or reflux esophagitis. Alcohol abuse is coded to uncomplicated, it is not dependence.

Explanation

GERD is coded to gastro-esophageal reflux disease without esophagitis which is a .9 code because it is not specified with esophagitis or reflux esophagitis. Alcohol abuse is coded to uncomplicated, it is not dependence.

6. A 7 year old is brought in to be seen for a red rash on his entire back, followed by diffuse epidermal exfoliation. Blood tests confirm Staphylococcal scalded skin syndrome (SSSS).

L00, L49.1 – Staphylococcal scalded skin syndrome and exfoliation due to erythematous condition involving 10-19 percent of body surface

L49.1, L00 - Exfoliation due to erythematous condition involving 10-19 percent of body surface with staphylococcal scalded skin syndrome

You look up this code under Syndrome-staphylococcal scalded skin. When you find the code it directs you to code an additional code to identify percentage of skin exfoliation which is the code L49.1 because it states entire back. Refer to rule of nines guidance, similar to a burn.

Explanation

You look up this code under Syndrome-staphylococcal scalded skin. When you find the code it directs you to code an additional code to identify percentage of skin exfoliation which is the code L49.1 because it states entire back. Refer to rule of nines guidance, similar to a burn.

7. A patient with AIDS is seen by her physician for severe dehydration. The final diagnosis by the physician is Salmonella with dehydration.

A02.8, B20 – other specified salmonella infection with human immunodeficiency virus (HIV ) disease

A02.9, B20 – salmonella infection unspecified with human immunodeficiency virus (HIV) disease

A02.9, Z21 – salmonella infection unspecified with asymptomatic HIV – HIV positive NOS

A02.8, Z21 – other specified salmonella infection with asymptomatic HIV – HIV positive NOS

You look up under infection, salmonella, no need to code the dehydration that is a symptom of the salmonella infection. You then code the HIV disease secondary (can just look up under HIV).

Explanation

You look up under infection, salmonella, no need to code the dehydration that is a symptom of the salmonella infection. You then code the HIV disease secondary (can just look up under HIV).

8. A mother brings her 1-year-old daughter in to see the pediatrician. She has had a persistent rash on her legs, neck, and arms. Recently, the rash has progressed into painful, raised bumps. She is diagnosed with infantile atopic dermatitis and started on a corticosteroid ointment.

R21 – Rash and other non-specific skin eruption

L20.83 – Infantile (acute/chronic) eczema

L20.83, R21 – Infantile (acute /chronic)eczema with rash and other non-specific skin eruption

L20.9 – Atopic dermatitis unspecified

You look this code up beginning with the key word of eczema then go to infantile (due to any substance). Cannot find this code under dermatitis in which the diagnosis is documented in the question, very tricky one.

Explanation

You look this code up beginning with the key word of eczema then go to infantile (due to any substance). Cannot find this code under dermatitis in which the diagnosis is documented in the question, very tricky one.

9. Sepsis due to puncture wound of the lower back and pelvis without a foreign body, initial encounter.

Tricky one! Patient presented truly with sepsis due to a puncture wound in their back. The R65.10 is the principal diagnosis. The injury code indicates that it is a puncture wound of the lower back and pelvis but it does not penetrate into the retro peritoneum, the last character of the code indicates that it is an initial encounter. The A41.9 code is for sepsis, unspecified organism.

Explanation

Tricky one! Patient presented truly with sepsis due to a puncture wound in their back. The R65.10 is the principal diagnosis. The injury code indicates that it is a puncture wound of the lower back and pelvis but it does not penetrate into the retro peritoneum, the last character of the code indicates that it is an initial encounter. The A41.9 code is for sepsis, unspecified organism.

10. Personal history of liver cancer.

C22.9 – malignant neoplasm of liver not specified as primary or secondary

Z80.0 – family history of malignant neoplasm of digestive organs

D01.5 – carcinoma in situ of liver, gallbladder and bile ducts

A little tricky but not too bad...Look under history, and then go to personal, malignant neoplasm, liver.

Explanation

A little tricky but not too bad...Look under history, and then go to personal, malignant neoplasm, liver.