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 Review each case study and select the correct ICD-10-CM diagnostic code. Please be aware that when an answer consists of more than one code, there will be an answer blank for each code, NO handwriting, and code all the cases

 Review each case study and select the correct ICD-10-CM diagnostic code. Please be aware that when an answer consists of more than one code, there will be an answer blank for each code, NO handwriting, and code all the cases

Instructions: Review each case study and select the correct ICD-10-CM diagnostic code. Please be aware that when an answer consists of more than one code, there will be an answer blank for each condition: Review each case study and select the correct ICD-10-CM diagnostic code. Please be aware that when an answer consists of more than one code, there will be an answer blank for each code, NO handwriting, and code all the cases
Case 1
Office Note
This 7-year-old male presents today with redness OU. Upon examination, the conjunctiva is swollen. He is experiencing no other symptoms.
Dx: acute conjunctivitis
Eye ointment is given. Instructed to return in 10 days.
ICD-10-CM Code Assignment…….x……
Case 2
ER Visit Note
This 37-year-old male presents to the ER with pain in his eye. The exam shows an object in the right lower eyelid. Because the object is deeply embedded in the skin, I am asking for a consultation from Dr. Ferrar. The object is retained in the lower right eyelid. The patient was sent to Dr. Ferrar’s office.
ICD-10-CM Code Assignment……x……, ……x……..

Case 3
Office Visit Note
This 54-year-old man works on a dairy farm and 2 weeks ago he “got something in my eye.” Exam of the eyes reveals that there are no foreign objects in the eyes at this time. The left eye is red and there is an abscess of the right upper eyelid. The patient was given antibiotics, drops, and patient education material. He was instructed to follow up with me if the eye becomes worse or in 10 days.
ICD-10-CM Code Assignment………….

Case 4
Ambulatory Surgery Discharge Note
This 74-year-old female patient underwent cataract extraction with intraocular lens replacement in her left eye due to anterior subcapsular polar senile cataracts. The surgery was uneventful and she was instructed to follow up in my office in 6 days.
ICD-10-CM Code Assignment ………….

Case 5
Office Note
This 1-year-old male child presents to the office today from a referral from Dr. Smith in pediatrics.
Dr. Smith has noted altered eye movements upon examination.
Examination:
The child’s left eye has convergent concomitant strabismus. The right eye is normal.
Treatment:
At this time I am going to conservatively treat the child and cover the right eye to force the left eye to function normally. If the eye does not respond, I will then discuss with the parents the need for corrective lenses or surgical intervention if more conservative treatment fails.
ICD-10-CM Code Assignment………….
Case 6
Office Note
This 53-year-old female patient returns to the office today to follow up after having fluorescein angiography.
She still reports loss of central vision. At this time she is still able to read. She is also a smoker.
I have reviewed the angiography report, which confirms macular degeneration in both eyes. I informed the patient that cigarette smoking is a risk factor that contributes to the disease and advised her to stop smoking. I also informed her that she should wear sunglasses that block ultraviolet light and gave her information about the disease process. She is to read the information that contains information about laser surgery and the risks and benefits of this surgery for this disease. I would like to see her in 4 months to assess the disease process.
ICD-10-CM Code Assignment……..x…….,…….x…….
Case 7
Office Note
This 4-year-old male patient is brought to my office today by his mother. She states that he is consistently confusing the colors red and green. I had the child view various Ishihara Color test plates and testing revealed color blindness.
ICD-10-CM Code Assignment:…………
Case 8
This 69-year-old male patient presents to the office today complaining of an irregular floating spot in his left eye and blurred vision.
Ophthalmoscope Examination:
Examination revealed no findings in the right eye.
In the left eye, there is a separation of the inner layers of the retina with fluid in the subretinal space.
There is also a retinal break.
Assessment: retinal detachment with retinal break
Plan: Patient will be scheduled for surgery
ICD-10-CM Code Assignment………….

Case 9
Observation Note
This patient is being placed in observation due to an increase in the symptoms of her acute angle-closure glaucoma in her right eye, severe stage. She is being placed on IV meds to see if symptoms decrease. She will be monitored and then admission for peripheral iridectomy will be made if needed.
ICD-10-CM Code Assignment…………

Case 10
Office Note
Upon examination, there is a small mass on the patient’s right upper eyelid. On the eversion of the lid, there is an elevated reddish-yellow area on the conjunctival surface. The patient was instructed to apply warm compresses to open the mass and to place Sulfomamide eye drops in the eye as prescribed.
Assessment: chalazion
ICD-10-CM Code Assignment……………

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