Student’s Name
Instructor’s Name
Course
Date
Coding Patient Cases
Case One
Code I25.9, Code E66.01, Code N23, Code R60.0
Code I25.9 to cover the group of chronic coronary diseases, including stable angina and myocardial infraction. The key point behind the code in the patient’s medical information is coronary heart disease. Code E66.01 as the case states the patient experiences morbid obesity. The patient is a severely obese adult based on their body mass index. Code N23 to cover the unspecified renal colic. According to the clinical information, the patient has severe pain in the lower back which is mostly associated with kidney stones. The persistent pain stretches to the groin and labia. Code R60.0 as diagnosis for the localized edema. The patient has swelling on the ankle, leg and lower extremity.
Case Two
R26.0, M47.812, G90/09
R26.0 for ataxic gait is identified as the clinical information educates that there is impairment in the ability to coordinate movements and pass sensory feedback. Such a condition is often associated with cognitive disorders. Code M47.812 is for spondylosis in the cervical region. The code covers the loss of motor function at the cervix, indicated in the case as cervical spndylosis. Code G90.09 for idiopathic peripheral neuropathy connects the gait disorder with the loss of neural function. The gait disorder could be the causal factor behind the peripheral neuropathy. The key point behind the code from the clinical information is peripheral neuropathy.
Case Three
F41.8, E78.5, 125.10, 167.9, K21.9
As per the clinical information, the patient has been sent for psychiatric treatment. Therefore, the primary problem is anxiety with severe depression. F41.8 is the medical code for anxiety with depression, justifying its position in the sequence of codes (Green 65). The patient also has a medical history of hyperlipidemia (E.78.5). Similar to the first case, 125.1 is the code for coronary heart disease. 167.9 is the code for cerebrovascular disease while K21.9 is the code for the gastro-esophageal reflux. Addressing the anxiety is bound to assist in resolving the eating disorder behind the reflux and hyperlipidemia. Minimized eating is bound to reduce the amount of lipids in the patient’s blood.
Case Four
F03.90, K59.09, K60.2
The patient seems to be suffering from an extreme case of dementia. The clinical information states the patient has moderate and mixed dementia with behavioral disturbance. The ICD-10-CM code for the disorder is F03.90. The behavioral disruption could explain the patient’s abnormal bowel movements. K59.09 is the identified code for chronic constipation, as the patient is suffering from constipation with overflow incontinence. The sight of blood in the feaces indicates possible anal fissure, whose code is K60.2. Dementia is the leading code because the treatment provided to the patient highlights a lack of cognitive and physiological autonomy in the patient. The goal was to reduce pain and not include any behavioral modifications.
Case Five
H57.11, M25.551
The case does not present a problematic diagnosis as the ICD-10-CM diagnosis is for two identifiable conditions only. According to the clinical information, the patient has tenderness in the frontal sinus, eyes are puffy and pain at the right hip. H57.11 connects the pain in the orbital area to the sinus infection, which could be the causal factor behind the fever. On the other hand, code M25.551 follows the pathology of the right hip pain. The key symptom behind the diagnosis is the pain and pressure from the right orbital area.
Works Cited
Green, Michelle. Understanding Health Insurance: A Guide to Billing and Reimbursements [16th Ed]. Cengage Learning, 2022.
Souza, Julio et al. “Quality of Coding Within Clinical Datasets: A Case-Study Using Burn-Related Hospitalizations.” Burns: Journal of The International Society for Burn Injuries vol. 45, no. 7, 2019, pp. 1571-1584. doi: 10.1016/j.burns.2018.09.013