Question

Same day, surgery- what are the ICD 10 codes? how do you break these down? could some let me know? greatly apperciate it.

This is a 75-year-old white female presenting with a recent increase in size of her thyroid gland on the right side. It gives her trouble swallowing but is otherwise asymptomatic for thyroid disease. She has had a thyroid mass for many years. There is no family history of thyroid disease. Thyroid scan shows a large nodule, and ultrasound reveals that the mass is mostly solid but with some cystic component. She is euthyroid. Past medical history is positive for coronary artery disease with angina, recent cataract surgery on the left eye, congestive heart failure, hypertension, and adult-onset diabetes mellitus. Medications: Isordil 20 mg by mouth every 6 hours, propranolol 80 mg by mouth every 6 hours, hydrochlorothiazide 100 mg by mouth 4 times daily, Nitro-Bid paste 1½ inch every evening, nitroglycerin 0.4 milligrams sublingual as needed, Valium 10 mg by mouth 3 times daily. No allergies. No smoking. No ethanol use. REVIEW OF SYSTEMS: Positive for two-pillow orthopnea, nocturia times 2; occasionally paroxysmal nocturnal dyspnea and edema, none recently, however. Dipstick reveals 1 to 21 sugar in urine. The patient has lost about 25 pounds on the recent diet. Physical: HEENT: Left cataract removed, right eye with cataract, thyroid not inflamed. Neck: Supple, thyroid enlarged on right side extending to isthmus. Left side feels normal. Lungs: Clear. Breasts: Benign. Heart: Regular rate with positive S4, no murmur heard. Abdomen: Protruberant umbilical hernias, soft, nontender, no masses. Extremities: No edema, pulses 21 and symmetrical and no focal motor or neurological deficits. Impression: Thyroid nodule. On 4/13, the patient was taken to the operating room where she underwent subtotal thyroidectomy for her enlarged thyroid. Frozen section diagnosis was nodular thyroid tissue consistent with follicular adenomas. She underwent the surgery well and did well in her postoperative course. Blood pressure was 130/80. She will be discharged today on her preadmission medications. She will be seen by Dr. Numann by appointment. DIAGNOSES: Thyroid follicular adenoma. Hypertension._______________________________________________________________________________________

22.The patient was admitted with gross hematuria following a long duration of prostatic symptoms and intermittent hematuria for several days. After the insertion of the Foley catheter and drainage of 400 cc of grossly bloody urine, chemistry tests revealed that he was in chronic renal insufficiency with a BUN of 66. His urinary output was very adequate. IVP showed poorly functioning kidneys but enough also to show an elevation of the bladder floor consistent with enlarged prostate (benign). Cystoscopy was carried out to rule out other causes of hematuria and the bladder found to be heavily trabeculated with many diverticuli and again a large prostatic gland. DIAGNOSES: Chronic renal insufficiency. Bladder diverticula. Benign prostatic hypertrophy._______________________________________________________________________________________

23.This 17-year-old white female was admitted to the hospital with the chief complaint of a past history of recurrent bouts of tonsillitis, having missed three days of school this year because of a severe bout and having another sore throat that started as soon as the penicillin stopped. She also has had earaches. She has had streptococcal sore throats. She consulted Dr. Port, who advised her to have a T&A. Physical examination revealed the tonsils to be large, but they appeared benign at the time of admission. She had an anterior lymphadenopathy. Laboratory studies on admission revealed hemoglobin 13.3 grams,

ematocrit 39.6, and white blood count 5700 with 42 polys. Urinalysis was negative. The bleeding time was 1 minute 30 seconds. Partial prothrombin time was 24 seconds. Chest x-ray normal. The patient was admitted to the hospital, prepared for surgery, and taken to the operating room where, under satisfactory general endotracheal anesthesia, a T&A was performed. Following the operation, she had an uncomplicated postoperative recovery. That afternoon she was awake, alert, and afebrile; had no bleeding; no anesthetic complications. The tonsillar fossa were clean; she is accordingly discharged on April 13 to see Dr. Port in one week and me in two weeks. DIAGNOSES: Diseased and hypertrophied tonsils and adenoids. Past history of recurrent bouts of streptococcal sore throats and tonsillitis.

24.This is a 15-year-old who was involved in a truck and bicycle accident in August. He continued to have problems with his right knee. He was referred to Dr. Jones, who diagnosed him as having torn medial meniscus of right knee as the sequela of previous fracture right patella and knee soft tissue injuries. Patient was admitted to the hospital on August 17 and underwent surgery that consisted of arthrotomy and medial meniscectomy of right knee. Patient did well on a postoperative period and was sent home in good condition.DIAGNOSIS: Bucket-handle tear of medial meniscus, right knee. (Sequela.)

25.Two weeks ago on a routine examination, Dr. Woughter detected a firm ridge in the right lobe of the prostate, became suspicious, and suggested to the patient that he have this biopsied at an early date. Patient presents now for biopsy procedure. A needle biopsy of the prostate reveals adenocarcinoma of prostate. Pathology results report adenocarcinoma of prostate. I have advised a radical prostatectomy. DIAGNOSIS: Carcinoma of prostate.

Answer 1

ICD-10 - International classification of diseases and health related problems -10th version.

It is used in health insurance, to measure the morbidity and mortality rates, track the health care statistics etc.

ICD 10 CM stands for ICD 10 Clinical modification- It is used in outpatient settings, nursing homes.

ICD 10 PCS stands for ICD 10 Procedural coding system - It is used in inpatient settings, hospitals.

ICD 10 code for following disease conditions and surgeries:

• ICD10 CM- D44.0- Thyroid follicular adenoma
• ICD 10 CM- I10- Hypertension
• ICD 10 CM- H25.9- Age related cataract at right eye
• ICD 10 CM- H59.022 - Lens fragments at left eye after cataract surgery
• ICD 10 CM-  Z90.89 - Subtotal thyroidectomy
• ICD 10 CM- I50.9- Congestive heart failure
• ICD 10 CM- I25.111- Coronary artery disease with angina

22.

• ICD 10 CM - N18.9- Chronic renal insufficiency
• ICD 10 CM- N32.3 - Bladder diverticula
• ICD 10 CM - N40- Benign prostate hypertrophy

23.

• ICD 10 CM- J35.9- Disease of the tonsil and adenoid
• ICD 10 CM- J35.3- Hypertrophy of tonsil and adenoid
• ICD 10 CM -J02.0- streptococcal sore throat
• ICD 10 CM- J35.01 - Chronic tonsillitis

24.

• ICD 10 CM-S83.211A-Bucket-handle tear of medial meniscus, right knee.

25.

• ICD 10 CM-D07.5- Carcinoma of prostate