Medical Coding Assignment: ICD-10-CM Guidelines and Case Analysis

This assignment delves into the core concepts of medical coding, addressing key aspects such as principal diagnosis, abstracting physician notes, differentiating between co-morbidities and manifestations, and understanding external cause codes. It explores the minimum coding requirements for sequela, the application of Z codes, and the distinctions between outpatient and inpatient coding guidelines. The assignment also provides a detailed analysis of various case studies, applying ICD-10-CM codes to accurately represent patient conditions, from routine examinations to adverse drug reactions, injuries, and specific illnesses like asthma and cancer. The student provides the correct medical codes for each case study, along with explanations. The assignment concludes with a list of relevant references.

Running head: Medical coding
Medical coding
Name of the student:
Name of the university:
Authors notes:

1MEDICAL CODING
1.Explain what the principal or first-listed diagnosis is for a hospital admission.
For getting admitted in a hospital there is a need for specific illness or injury through
which diagnosis and treatment can follow and this is a basic principle for getting admitted.
2.What does abstracting the physician's notes mean?
A physician note consists of the medical details and diagnostic process of the patient
which is vital for the treatment (Gottlieb). In this context abstracting from the physicians note
mean to analyse the information for potential use for a specific illness.
3.Explain the difference between co-morbidities and manifestations.
Comorbidity is related medical term which states the condition when there is an
occurrence of more than one condition in a person. For instance social anxiety and major
depression if found together in a person it is known as comorbidity. Clinical manifestations
are a form of symptoms presented in a person as a result (Zeng et al.) of one single illness and
its effect may vary from moderate to severe. The contrasting difference between the two is
the symptoms where in comorbidity it occurs as a result of interactions of similar disease
while in clinical manifestations symptoms varies.
4.What is an external cause code, and what part of the patient encounter does it tell?
External codes are form of secondary codes especially in injury related and the
guidelines have been especially redone for ICD-10-CM guidelines. These guidelines are
suited for patients with diabetes and gives additional information of the patient injured which
is not reported in other codes and are exclusive.
5.What is the minimum number of codes required to code a sequela or late effect, and in
what sequence or order are they listed?

2MEDICAL CODING
The condition of nature and late effect code are the basic requirements for the
sequential coding of late effect or sequela. There is a requirement of minimum number of two
codes for the sequela coding.
6.What is a Z code, and when would it be assigned?
Z codes are provided in ICD 10 guidelines which is related to health services not
mentioned in other code guidelines (Ogden et al.). The guidelines are special code for first
listed or secondary treatments. Z codes are assigned for special purposes like in specific
illness or in special therapy like radiation therapy or to indicate the status of new borns.
7.Explain the difference in the guidelines between coding for outpatient services and
coding for inpatient services.
In patient coding is more complex than out patient coding as more documentation is
required in outpatient and given more care as they stay in hospital for 24 hours or more. ICD-
9/10-CM guidelines are needed to be followed for both in patient and outpatient coding.
Outpatient coding is more of detailed medical details as there is extended stay as compared to
in patient coding.
8.When is it appropriate to code from the Alphabetic Index?
The alphabetical index is coded to make a procedure code, which would contain all
information. It is always appropriate to always continue with alphabetical index as this
assures efficient procedure.

3MEDICAL CODING
Case studies:
1 .Upon studying the first case study it is clear that Jonathan is not suffering from any
serious illness so the most appropriate code would be Z00-Z13 as this code states the
guidelines when the person encounters health related services for tests or examinations.
Admission in the hospital needs a particular serious or non-serious illness. Therefore, the Z13
code represents the need. Jonathan is not suffering from any serious illness, but to play a
football match he needs a fitness certificate, which can be guided by the Z code, which
influences health status.
2. Marilyn chase an old patient had serious health hazards when sleeping pill was
administered. Therefore, in this case it follows the T code of medical code that is ICD 10
CM. The coding of adverse drug reactions, which has been prescribed, needs to be have the
specific code in order. This is a case of poisoning and unintentional.no external code is
required for cases related to poisoning (Buck and Carol).
3. The 27-year-old patient who fell from the horse and admitted in the emergency
room due to sprained back. The perfect medical code designated for this condition is S30-39,
which deals with the abdomen and back pain resulting out of accidents.
4. The female patient was diagnosed with Otitis externa in her external ear and the
appropriate code for the medical coding is H60.02, which governs the function of left ear in
the external part.
5. The 13-year-old patient was suffering from asthma and the medical code that suits
it is J45 and sub groups are there under it depending on what type of asthma he is suffering
from like whether mild or moderate persistent (Ghaderi et al.). The correct use of nebuliser
also follows the guidelines of J45 as it includes every aspect of the illness.

4MEDICAL CODING
6. For someone like Eleanor a woman in early 40s suffering from pap smear is a
common gynaecological disease which is identified in the code O98. In the given code there
is no special mention for pap smear or any related gynaecological disease but as it is
concerned with gynaecology and not specified elsewhere O98 can be said as the medical
coding for this illness.
7. A 9 day old born is a neonate and medical code P refers to the guidelines related to
babies aged 4 weeks or lesser. There is no specific code for the congenital tags that the baby
developed in the ear but as it is related to neonates this can be categorised under P35 coding.
8. Millie Andujar a women in her 40s goes to the doctor for diagnosing
mammography for she has advanced risk of breast cancer. A family medical result says that
the women is in high risk as her mother died of cancer and may be congenital. C50 of
medical coding defines the results of neoplasms in breast and is appropriate for the following
case (Schneble et al.). Z14 also defines the situation, which confers health service for genital
disease and susceptibility to the disease. Therefore, both the codes and their knowledge is
required in this condition.
9. The patient named Edward is an aged person and has been diagnosed with
malignant melanoma, which is a form of cancer. The medical code that best describes the
symptoms and health effects is C43 as it deals with cancer and neoplasm related disorders.
10. The basic medical code that suits the given condition of second sunburn treatment
of the patient is L55, which deals with burn injuries in skin and sub cutaneous tissue (Haoran
et al.). To be more specific it can be said that L55.1 is related to the secondary burn and
treatment.

5MEDICAL CODING
11. There is no specific code for the 2-year-old boy who accidently consumed
ampicillin and was not prescribed by any physician. It was a situation of accident and
carelessness.
12. In the 4 year old female a jelly bean got stuck which blocked her nostrils thus
making it difficult for breathing so therefore codes specified for this condition is R06.00 that
deals with the breathing and respiratory condition.

6MEDICAL CODING
References
Buck, Carol J. Step-by-Step Medical Coding, 2017 Edition-E-Book. Elsevier Health Sciences,
2016.
Ghaderi, Kimeya F., Scott T. Schmidt, and Brian C. Drolet. "Coding and billing in surgical
education: a systems-based practice education program." Journal of surgical
education 74.2 (2017): 199-202.
Gottlieb, Laura, et al. "Integrating social and medical data to improve population health:
opportunities and barriers." Health Affairs 35.11 (2016): 2116-2123.
Ogden, Kate, Neela Swanson, and Janet McCarty. "Answers to Your ICD-10-CM Coding
Questions: The new code set in place since Oct. 1 has some clinicians revisiting their
coding practices. Here are answers to some of the most frequently asked questions."
The ASHA Leader 21.1 (2016): 30-32.
Schneble, Christopher A., et al. "Reliability of International Classification of Disease-9
Versus International Classification of Disease-10 Coding for Proximal Femur
Fractures at a Level 1 Trauma Center." The Journal of the American Academy of
Orthopaedic Surgeons (2019).
Shi, Haoran, et al. "Towards automated ICD coding using deep learning." arXiv preprint
arXiv:1711.04075 (2017).
Snider, Neal E., Feifan Liu, and Girija Yegnanarayanan. "Sequencing medical codes methods
and apparatus." U.S. Patent Application No. 15/710,319.
Zeng, Min, et al. "Automatic ICD-9 coding via deep transfer learning." Neurocomputing 324
(2019): 43-50.