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May 15, 2015
Test your coding knowledge with this scenario about coding bilateral upper eyelid with ICD-9, ICD-10... Learn More

April 24, 2015
Test your coding knowledge with this scenario about coding prostate cancer with ICD-9-CM, CPT, and H... Learn More

April 10, 2015
Test your coding knowledge with this scenario about coding right colon mass with ICD-9-CM, ICD-10-CM... Learn More

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2010 Code This! Scenarios

Code This!

2010 Code This Scenarios
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December 23, 2010 - The patient is a 62-year-old white male who underwent an excisional biopsy of a malignant melanoma 1.6 cm in diameter near the posterolateral aspect of the left upper arm.
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December 06, 2010 -

Subtalar fusion
Preoperative Diagnosis:
Subtalar joint degenerative joint disease, joint instability, chronic pain, and peroneal tendon atrophy

Postoperative Diagnosis:
Subtalar joint degenerative joint disease and peroneal tendon atrophy

Procedure Performed:
Subtalar joint fusion with external fixation device


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October 11, 2010 - Admitting Diagnosis: Fracture, femoral neck Principal Diagnosis: Transfusion associated circulatory overload (TACO)
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September 13, 2010 - Indications for Procedure Patient is an 88-year-old female who sustained a right intertrochanteric hip fracture after a fall. She has been taken to the operating room for an open reduction and internal fixation of this right hip fracture. Consent has been signed and can be found in the chart. Risks include death, infection, nerve or blood vessel injury, bleeding, need for blood transfusion, blood clots, failure to heal, and the need for further surgery.
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August 16, 2010 - Day One The patient is a 69-year-old female diagnosed with right lower-outer quadrant breast cancer, post lumpectomy. After initial consultation, the decision was made to treat via mammosite application BID for duration of 5 days and a total of 10 treatments. Due to the complexity of brachytherapy delivery, the physician will spend additional time planning treatment. The patient was brought to the CT simulator and was placed in the supine position.
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July 19, 2010 -

The setting is an outpatient hospital emergency room subject to the Outpatient Prospective Payment System (OPPS). A 67-year-old female presents to the emergency room following a minor car accident while the patient was driving home from her son’s house. The patient states she hit a side rail on the highway and that no other persons were injured. She complains of a headache caused by the force of the air bag deployment from the car steering wheel.

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June 18, 2010 -

The patient noted a large lump in the left side of the neck. On evaluation by the primary physician, it was felt this was a solid lesion. It was cold on thyroid scanning. The patient was euthyroid. It was felt the patient needed surgical excision of this large mass by thyroid lobectomy, followed by subtotal or total thyroidectomy if carcinoma was identified.

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May 28, 2010 -

Case Study: Chief Complaint: Inpatient consultation for multiple deep facial and neck abrasions.

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May 13, 2010 -

A 5-year-old girl is admitted to the observation department of the hospital following three days of abdominal pain, diarrhea, and vomiting. The abdominal pain is severe at times. She is lethargic and has decreased urinary output. She is unable to keep down clear liquids. She has a fever of 103. Review of systems was comprehensive. It included constitutional, neurological, ENT, eyes, cardiovascular, respiratory, gastrointestinal, endocrine, hematological

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April 22, 2010 -

This 14-month-old baby girl presents for nasolacrimal duct probing and dilation. The child has a history since birth of epiphora of both eyes, with worsening of the condition when she has a cold or is out on windy days. Besides tearing, she has crusting and drainage around the eyes. She was recently on antibiotics for conjunctivitis and increased mucous in the eye. Her parents have tried warm compresses and massage of the lacrimal sac, but that has not been helpful.

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April 06, 2010 -

The patient is a 67-year-old female who presents for a stereotactic core biopsy.

Preoperative diagnosis: Right breast mass
Postoperative diagnosis: Benign calcifications in right breast

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March 16, 2010 - A 72-year-old male Medicare patient presents to the outpatient radiology department for a cardiac transthoracic echo with treadmill exercise stress. An IV was started and the patient started running on the treadmill. Exercise duration 8 minutes 41 seconds. Patient was given 10 microliters of Definity by IV push.
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February 23, 2010 - The patient is a 49-year-old male with a history of “sharp grinding” neck pain for the past 5 to 6 years. The patient was involved in a shallow water diving accident in the 1980s that involved a cervical spinal cord injury with temporary paralysis. The patient did not have significant pain after the accident but developed “grinding” pain in the neck in the late 90s.
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February 09, 2010 - Case Study:
A 45-year-old female patient calls a new internal medicine physician to schedule an annual well-woman checkup with routine pelvic exam. The office indicates that their policy is to perform the preventive exam on the first exam and that the patient must return a week later for the pelvic exam.

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January 26, 2010 - Inpatient Surgical Coding
The patient has a previous history of a right infected hip replacement with prosthesis removal and antibiotic spacer placement performed six weeks ago. She will be readmitted today for second stage removal of previously placed antibiotic spacer and revision of a total hip replacement. She has been on IV antibiotic therapy for the past six weeks.

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January 12, 2010 - The patient is prepped and placed on cardiopulmonary bypass for a procedure involving a surgical team. The cardiothoracic surgeon opens the chest and inserts chest tubes. Immunosuppressive drugs are administered to the patient before, during, and after the operation.

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