Question

Using the techniques described in this chapter carefully read through the case study and determine the most accurate ICD-10-CM code(s) and external cause code(s) if appropriate. Remember, check the chapter specific, sub-chapter specific and category specific notations within the Tabular list. Patient: Lorraine Parnete Physician: Jason Nuouri, MD July 16, 2018 History A well-established, 67-year-old female patient (since 1991) has controlled hypertension with no complications. She is a smoker [cigarettes, about one pack a day] and takes clonidine and HCTZ for her hypertension, and estrogen to address menopausal symptoms. Overall, she is well and fully active. Examination Patient presents with fatigue, about 1 month duration, associated with the withdrawal from estrogen because of published data suggesting an increased risk of breast cancer and other complications. Exam includes complete review of systems. CXR [chest x-ray] and PPD (tuberculin skin test) are negative except for the following: cough with minimal sputum a low grade fever to about 100°F 5 pound weight loss Plan Order for CBC, glucose tolerance test, TSH. Patient to return to discuss lab results. Be sure to list the codes, one code per box, in the correct order, from top to bottom. Capitalization, punctuation, and spacing can impact whether or not your answer is correct. Follow coding best practices. What is/are the correct diagnosis code(s)?

Answer 1

J01.11- Acute recurrent frontal sinusitis

• J00-J99  Diseases of the respiratory system
• J00-J06  Acute upper respiratory infections
• J01  Acute sinusitis
• J32.1 frontal
• J01.10 acute
• J01.11 recurrent

J45.901allergic exacerbation of asthma

• J00-J99  Diseases of the respiratory system
• J40-J47  Chronic lower respiratory diseases
• J45  Asthma
• J45.90  Unspecified asthma
• J45.901 allergic exacerbation

R06.2 wheezing

• R00-R99 Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified
• R06 Abnormalities of breathing
• R06.2 wheezing

Z57.2 Occupational exposure to dust

• Z00-Z99 Factors influencing health status and contact with health services  
• Z55-Z65 Persons with potential health hazards related to socioeconomic and psychosocial circumstances
• Z57- Occupational exposure to risk factors
• Z57.2 dust