1.) A 63-year-old male patient, known to have emphysema, was advised by his physician to be admitted to the hospital to evaluate and treat his worsening lung condition. The patient quit smoking cigars 5 years ago, after he was told he had emphysema. The patient complained that his coughing and wheezing had become worse and his sputum was streaked with blood. A chest x-ray done on an outpatient basis the previous week showed a mass in the right main bronchus.  After admission, a fiber optic bronchoscopy and excisional biopsy of the right main bronchial mass was performed. The pathologic diagnosis of the biopsy examination was small cell type bronchogenic carcinoma located in the right main bronchus. A nuclear medicine bone scan found areas of suspicious lesions that were determined to be bone metastasis. The diagnoses provided by the physician at discharge were bronchogenic, small cell carcinoma of the right, main bronchus with metastatic disease in the bones, emphysema, and former nicotine dependence.

What Are The 4 ICD-10-CM Codes?

2.) A 98-year-old man was brought to his primary care physician by his family for his regular check-up. The man, who was very alert and oriented for his age, stated that he was feeling increasingly tired with each day, causing him to sleep 10 to 12 hours a day. He also stated he had lost his appetite and felt slightly nauseated all the time. His physician, concerned by these symptoms present in a patient of advanced age, advised admission. The patient was admitted for probable dehydration, which was later confirmed by examination and laboratory findings. Intravenous hydration was started. Other laboratory tests showed evidence of chronic kidney disease (CKD) stage 4 and hypertension. Further workup revealed a mass at the head of the pancreas. The patient began to experience neoplasm-related pain and was given low doses of morphine. The patient, having lived a long life, refused surgery, chemotherapy, and all other treatments, preferring to return home to die in peace. The patient and his family consented to hospice care at home and the patient was discharged .The physician's final diagnoses included the statement "probable carcinoma of the pancreas, hypertensive CKD Stage 4, dehydration."

What Are The 5 ICD-10-CM Codes?

3.) A patient with terminal carcinoma of the sigmoid colon with metastases to the liver was admitted to the hospital with hypotonic dehydration. The patient's hypotonic dehydration was the focus of the treatment with intravenous therapy, and the patient felt relief from his symptoms. Chemotherapy had been recently discontinued after discussions with the patient about its ineffectiveness in curing his disease and how sick the treatment made the patient feel. During the hospital stay, the patient and his family agreed to palliative care only, which was ordered along with  an order to "do not resuscitate" (DNR). The patient was discharged to home hospice.

What Are The 5 ICD-10-CM Codes?

4.) This is a 46-year-old woman who had biopsy-proven malignant melanoma and excision of the lesion on her forehead. Since the last visit the patient learned that her brother and possibly her father (who is now deceased) had lesions and moles removed that were skin cancer and, in her father's case, probably a melanoma. All three people shared the same history of growing up in a southern state with year-round extensive sun-related radiation exposure. The patient, her brother, and her father enjoyed fishing at the beach and rarely applied sunscreen lotion. On this occasion, she is brought back to the hospital outpatient department for a "wide excision" of the same location on her forehead where the lesion had previously been removed, 4 x 3 cm in area, at the site of the original excision. Because the affected area was her forehead, the patient asked for a plastic repair of the site. The surgeon agreed and documented that the plastic repair, which required the insertion of synthetic substitute, was not done for cosmetic reasons but done to avoid future possible painful scarring. The reason for the second excision was stated as "further excision as margins of initial excision showed evidence of remaining malignancy." The physician said this procedure was to "finish" the original excision to make certain the "margins are clean" and no malignant tissue remains. The pathology report states "normal tissues, margin clean, no evidence of remaining malignant melanoma." The patient will be seen in the office for suture removal and further treatment options are to be discussed.

What Are The 3 ICD-10-CM Codes?