Instructions: Review each case study and select the correct ICD-10-CM diagnostic code.no hand writing and answer all the cases
Case 1 Emergency Department Note
This 9-year-old male patient was brought to the ER by his mother. His left external ear is warm to touch, and it appears red and swollen. He has had a fever of 100 for the past 2 days. Upon otoscopic exam, the middle and inner ear are reviewed with no findings. There is definitely cellulitis of the external auditory canal. Antibiotics were given, and the patient was instructed to return to his doctor in 7 days or to call if the symptoms worsen.
ICD-10-CM Code Assignment....x.....
Case 2 Office Note
This 19-year-old female has been complaining of ear pain for 3 days and feeling tired.
EYES: Appear normal
NOSE: No findings
CERVICAL LYMPH NODES: Unremarkable
EARS: The right ear shows otitis media is present.
Antibiotics and drops given. Instructed to return in 10 days.
ICD-10-CM Code Assignment....x........
Case 3 Audiology Note
This 54-year-old male patient is being seen by me today to review the results of previous hearing tests and to determine a course of action for the hearing loss. Diagnostic testing reveals bilateral conductive hearing loss. The outcome of the testing was discussed with the patient and the patient will follow up with the audiology department to further discuss treatment options.
ICD-10-CM Code Assignment......x........
Case 4 Office Note
This is the third time in a 4-month period this year that this patient has been seen for myringitis. The patient was also seen last year three times for the same condition. Treatment options have not controlled the myringitis. I have referred the patient to Dr. Payal in the audiology department for further treatment for the chronic myringitis of the left ear.
ICD-10-CM Code Assignment........x.......
Case 5 Hospital Discharge Note
This 31-year-old male is being discharged today following correction of deformity of the right pinna that he acquired during a automobile accident. His stay was uneventful, the surgery corrected the deformity, and there were no complications. He is instructed to follow the discharge orders that were given to him and follow up in my office in one week.
ICD-10-CM Code Assignment......x.......
Case 6 Office Note
This 84-year-old patient presents today with a complaint of loss of hearing, tinnitus, and pain in her left ear.
Vital Signs: BP: 130/80, Weight: 194 pounds
Ear: Inspection of right ear—no findings
Inspection of left ear—there is impacted cerumen in the ear.
Mineral oil was placed in her ear and then the ear was irrigated and the wax removed.
ICD-10-CM Code Assignment......x.........
Case 7 Office Note
This patient is returning to the office today to discuss having a stapedectomy or obtaining a hearing aid to treat bilateral otosclerosis. The patient has discussed this with his family and he would rather not have surgery at this time. I have referred him to the hearing clinic to be fitted for a hearing aid in both ears.
ICD-10-CM Code Assignment .......x.....
Case 8 Emergency Department Note
This 10-year-old patient is complaining of ringing in his left ear and a headache for the last 3 days. He has had a fever of 101 for the last 2 days. Otoscopic examination is suggestive of acute mastoiditis. CT scan revealed inflammation of the mastoid bone in the left ear. Antibiotics were prescribed and he was instructed to follow up with his primary care provider in 5 days.
ICD-10-CM Code Assignment.......x.......
Case 9 Office Note
This 10-month-old patient is brought to the office by his father. The father states that the child is pulling on his right ear, has been running a fever, and has been crying for no reason. Temperature is 100.4.
Otoscopic examination reveals a bulging tympanic membrane in the right ear, which is red and swollen.
Left ear is normal.
Assessment: acute suppurative otitis media
Plan: Tylenol for pain and amoxicillin as written
ICD-10-CM Code Assignment.........x.........
Case 10 Skilled Nursing Facility Note
This 86-year-old female has been tested for hearing loss. I am seeing her today to discuss the need for a hearing aid. She is not able to hear well in both ears, as confirmed by testing, due to sensorineural hearing loss. Today I am writing a script for her so she can be fitted for hearing aids.
ICD-10-CM Code Assignment ......x.......