Exam 23: Symptoms, Signs, and Abnormal Clinical Laboratory Findings

Signs and symptoms that are associated routinely with a disease process are coded as an additional diagnosis if they are recorded in the patient's record.

When coding the phrase "acute enlarged cervical lymph nodes," the main term to reference in the index is _____.

Abnormal retinal function study is reported with code _____.

Emergency department note: "This 59-year-old with no known history of any pathology was brought to the ED and pronounced dead upon arrival." This case would be reported with code ____________________.

Office note: "This patient returns today for discussion of his elevated PSA. We discussed the possibility of prostate cancer and I told him that I want to have him undergo a biopsy." This encounter would be reported with code(s) ____________________.

Sam presents to the office today with back pain and a cough. After workup it is determined that he has a ruptured disk. The origin of the cough is undetermined at this time. The back pain and cough would both be reported.

Emergency department note: "Sarah presents to the ER today due to fainting. She has fainted on a number of occasions due to a drop in her blood pressure. Previous workup has not indicated any cardiovascular diseases. At this time her blood pressure is 125/80. I am referring her to a cardiologist for additional testing." This encounter would be reported with code(s) ____________________.

Office progress note: "Tim is being seen today due to a complaint of painful urination. This may be caused by stenosis of the urethra." This case would be reported with code(s) _____.

Wheezing is reported with code _____.

Office visit note: "This 4-year-old patient presents today with fever and chills. Exam reveals no abnormal findings in the HEENT. Chest is clear. There are no abnormal findings in the abdomen. The rest of the examination is unremarkable. I am ordering blood work to rule out infection." This case would be reported with code(s) ____________________.

Polly presents to the office today complaining of weakness and feeling tired for the last week. This is an example of symptoms.

High blood pressure is an example of a symptom.

Office note: "This patient has had numerous blood tests, and it is confirmed that there is a drop in hematocrit of undetermined origin." This case should be reported with code(s) ____________________.

Febrile seizure is reported with code _____.

Drug testing has revealed cocaine in a blood sample. This would be reported with code ____________________.

When ICD-10-CM assigns a combination code that identifies both the definitive diagnosis and a common symptom, an additional code for the symptom should be assigned.

Aphasia is reported with code R47.0.

A pediatric office note records that a child is a late walker. The code to assign for this is ____________________.

Kim is seen by Dr. Smith today. She is complaining of right upper quadrant pain. Dr. Smith records probable gall stones in her record. The first-listed diagnosis should be gallstones.

Cardiac murmur is reported with code _____.