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chapter4

The document outlines the ICD-10-CM codes for various patient diagnoses, including E10.40 for Type I diabetes with diabetic neuropathy and J01.90 for acute sinusitis. It also details codes I25.10 for coronary artery disease, E78.5 for hyperlipidemia, Z87.891 for a history of tobacco use, and Z79.899 for long-term drug therapy. Additionally, it describes a surgical procedure for bilateral profound sensorineural hearing loss, with the postoperative diagnosis coded as H90.3.

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chapter4

The document outlines the ICD-10-CM codes for various patient diagnoses, including E10.40 for Type I diabetes with diabetic neuropathy and J01.90 for acute sinusitis. It also details codes I25.10 for coronary artery disease, E78.5 for hyperlipidemia, Z87.891 for a history of tobacco use, and Z79.899 for long-term drug therapy. Additionally, it describes a surgical procedure for bilateral profound sensorineural hearing loss, with the postoperative diagnosis coded as H90.3.

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What diagnosis/es code(s) are reported? ICD-10-CM Codes: E10.40, J01.

90 Rationale: The patient is


diagnosed with Type I diabetes. The patient has diabetic neuropathy, which is a diabetic manifestation.
From the Index to Diseases and Injuries, look for Diabetes, diabetic/type I/with/neuropathy. You are
referred to E10.40. To locate the code for acute sinusitis, look for Sinusitis/acute. You are referred to
J01.90. Verify code selection in the Tabular List. Case 4 S: The patient presents today for reevaluation
and titration of carvedilol for his coronary artery disease and hyperlipidemia. |1| His weight is up 7
pounds. He has quit smoking. He has no further cough and he states he is feeling well except for the
weight gain. He states he doesn’t feel he’s eating more but his wife does state that he’s eating more.
We’ve been attempting to titrate up his carvedilol to 25 mg twice a day from initially the 6.25. He has
tolerated the titration quite well. He does get cephalgias on occasion. He states he has a weak spell but
this is before he takes his morning medicine. I did update his medical list here today. I did give him
samples of Lipitor. O: Weight is 217, pulse rate 68, respirations 16, and blood pressure 138/82. HEENT
examination is unchanged. His heart is a regular rate. His lungs are clear. A: 1. CAD |2| 2. Hyperlipidemia
|2| P: 1. The plan is samples of Lipitor for two months’ supply that I have. 2. We’ve increased his Coreg
to 25 mg bid. He’ll recheck with us in six months.
_____________________________________________________________ |1| Patient returns for
treatment of CAD and hyperlipidemia. |2| Select the codes for the definitive diagnoses.
_____________________________________________________________ What diagnosis/es code(s)
are reported? ICD-10-CM Codes: I25.10, E78.5, Z87.891, Z79.899 Rationale: From the Index to Diseases
and Injuries, look for Disease, diseased/artery/coronary. You are referred to I25.10. The patient also has
hyperlipidemia. In the Index to Diseases and Injuries, look for Hyperlipemia, hyperlipidemia. You are
referred to E78.5. There is an instructional note under category code I25, Use additional code to identify
exposure to/history of/use of/or dependence of tobacco. The documentation indicates that the patient
quit smoking. He has a history of tobacco use, reported with Z87.891. Because there is reevaluation of
medication the patient is taking for CAD and hyperlipidemia, code Z79.899 is reported. Look for Long-
term (current) (prophylactic) drug therapy (use of)/ drug, specified NEC Z79.899. Verify the codes in the
Tabular List. Case 5 Preoperative Diagnosis: Bilateral profound sensorineural hearing loss. Postoperative
Diagnosis: Bilateral profound sensorineural hearing loss. |1| Procedures Performed: 1. Placement of left
nucleus cochlear implant. 2. Facial nerve monitoring for an hour. 3. Microscope us

Chapter 4 ICD-10-CM Coding Chapters 1–11 Anesthesia: General. Indications: This is a 69-year-old
woman who has had progressive hearing loss |2| over the last 10–15 years. Hearing aids are not useful
for her. She is a candidate for cochlear implant by FDA standards. The risks, benefits, and alternatives of
procedure were described to the patient, who voiced understanding and wished to proceed. Procedure:
After properly identifying the patient, she was taken to the main operating room, where general
anesthetic was induced. The table was turned to 180 degrees and a standard left-sided postauricular
shave and injection of 1% lidocaine plus 1:100,000 epinephrine was performed. The patient was then
prepped and draped in a sterile fashion after placing facial nerve monitoring probes, which were tested
and found to be working well. At this time, the previously outlined incision line was incised and flaps
were elevated. A subtemporal pocket was designed in the usual fashion for placement of the device. A
standard cortical mastoidectomy was then performed and the fascial recess was opened exposing the
area of the round window niche. The lip of the round window was drilled down exposing the round
window membrane. At this time, the wound was copiously irrigated with Bacitracin containing solution
and the device was then placed into the pocket. A 1 mm cochleostomy was then made and the device
was then inserted into the cochleostomy with an advance-off stylet technique. A small piece of
temporalis muscle was then packed around the cochleostomy and the wound was then closed in layers
using 3-0 and 4–0 Monocryl and Steri-Strips. A standard mastoid dressing was applied. The patient was
returned to the anesthesia, where she was awakened, extubated, and taken to the recovery room in
stable condition. _____________________________________________________________ |1| Report
the postoperative diagnosis. |2| The diagnosis is documented as the indication for the surgery.
_____________________________________________________________ What diagnosis/es code(s)
are reported? ICD-10-CM Code: H90.3 Rationale: The patient has bilateral sensorineural hearing loss.
From the Index to Diseases and Injuries, look for Loss (of)/ hearing (see also Deafness). Look for
Deafness/ senso

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