ICD 10 CODING PATIENT SCENARIOS - c.ymcdn.com

1 ICD 10 CODINGPATIENT SCENARIOSJune 20152 Mrs. Gonna Fall Dizziness 55 Year old with 9 days of insidious onset of dizziness. PATIENT reports room spinning after transitional movements x 9 days. Denies nausea / vomiting Positive Right Dix Hallpike Ataxic gait tracking Activities Balance Confidence Scale (ABC 6) score = 37%3 Mrs. Gonna Fall DizzinessICD 9 CM Diagnosis CodesICD 10 CM Diagnosis paroxysmal positional vertigo (BPPV) paroxysmal vertigo right and giddinessR42 Dizziness and Abnormality of gait4 ICD 10 Abnormalities of Gait and Mobility gait Paralytic gait in walking, not elsewhere classified Other abnormalities of gait and mobility on Other abnormalities of gait and mobility Unspecified abnormalities of gait and mobility R27 Other lack of coordination.

2 Unspecified Other lack of coordination lack of coordination5 Rachel Limpy Post Op ACL 35 year old female s/p R ACL repair with medial meniscal repair ACL and Bucket Handle tear of medical meniscus during softball game Presentation: Knee pain, swelling, decreased ROM & strength, difficulty walking (WBAT on crutches) Lower Extremity Functional Scale LEFS score = 27%6 Rachel Limpy Post Op ACLICD 9 CM Diagnosis CodesICD 10 CM Diagnosis of anterior cruciate ligament Sprain of anterior cruciate ligament of right knee, subsequent of medial cartilage or meniscus of knee, Bucket handle tear of medial meniscus, current injury, right knee, subsequent in joint, lower in right of joint, lower , right of joint, not elsewhere classified, lower of right knee, not elsewhere weakness (generalized) weakness (generalized)

3 In walking, not elsewhere classified7 Fred Ouchy Ankle Sprain 45 year old male slipped on ice and sprained his L ankle Arrives to therapy evaluation in walking boot issued by the referring physician Left ankle decreased ROM, MMT, SLB, difficulty walking and point tenderness to medial malleolus Orders are for evaluation and treatment Lower Extremity Functional Scale Score = 46%8 Fred Ouchy Left Ankle SprainICD 9 CM Diagnosis CodesICD 10 CM Diagnosis and strains of ankle, unspecified of unspecified ligament of left in Difficulty in Walking, not elsewhere of joint, lower , left of joint, not elsewhere classified, ankle and of left ankle, not elsewhere in joint, ankle and in left ankle and joints of left foot9 Samantha Ice: Frozen right shoulder 52 year old female with right shoulder pain; 6 on 1 10 scale.

4 Significant decreased ROM noted. Difficulty with ADLs including carrying briefcase, driving, dressing and cooking noted. PATIENT states sleep is also being affected Disabilities of the Arm, Shoulder & Hand (Dash) Score = 72%10 Samantha Ice : Frozen right shoulder Active and passive range of motion to right shoulder significantly decreased. Capsular Pattern noted Firm end feel Neurological exam normal History of type II diabetes 11 Samantha Ice: Frozen right shoulderICD 9 CM Diagnosis CodesICD 10 CM Diagnosis capsulitis of capsulitis of right in Joint, Shoulder Region in Right of joint, not elsewhere classified, shoulder Stiffness of right shoulder, not elsewhere with unspecified complication, type II or unspecified type, not stated as Type 2 diabetes mellitus with unspecified complications12 Henry Sparky Flexor Tendon Repair 32 fire fighter hyperextension injury to L hand while working on a hydrant PIP contracture Post flexor tendon repair to the FDS.

5 Flexor tenolysis and capsulectomy Pain 8/10, DASH Score , joint contracture, edema and weakness Extension orthosis indicated13 Henry Sparky Flexor Tendon RepairICD 9 CM Diagnosis CodesICD 10 CM Diagnosis Pain in hand pain Left hand joint pain of joint, Contracture, left tendon Other specified injury of long flexor muscle, fascia and tendon of left thumb at wrist and hand level, subsequent encounter