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Asked by Wsmd198
List the appropriate ICD 10 codes for each case study.
Office Visit Note
This patient returns to my office today following delivery of a female infant 2 weeks ago. She states that she is having bilateral breast pain that is increasing in intensity for the last 4 days. Upon exam both breasts appear red and warm to the touch, confirming puerperal mastitis. The patient is very anxious about this and I informed the patient that this is nothing to be alarmed about. The patient was instructed to apply a heated compress to both breasts and to take Tylenol for the discomfort and to wear a firm supporting bra to increase her comfort.
She was instructed to return to me if the symptoms increase.
One ICD 10 code needed____________________
Office Visit Note
This 42-year-old pregnant patient is being seen today for a 24-week prenatal visit. This is her first pregnancy. Vital signs are normal. Blood glucose is within normal limits. Fetal heartbeat is normal. The pregnancy is progressing well. I will see her again in 2 weeks.
Two ICD 10 codes needed___________________ ___________________________
Physician Office Visit
This 27-year-old female, who is 12 weeks pregnant, is experiencing increased thirst, increased urination, increased fatigue, and bouts of nausea. An in-office blood sugar reading was 245, so a glucose tolerance test was ordered. The results confirmed gestational diabetes. Insulin is not necessary at this time.
Two ICD 10 codes needed___________________ ___________________________
Discharge Summary
ADMISSION DATE: 5/6/XX, Discharge date: 5/8/XX
HISTORY:
This patient is gravida 2, para 1 and was seen in my office for all of her prenatal visits. Her prenatal course was uneventful. She was admitted with a history of contractions every 3 to 5 minutes. Cervix was 100% effaced and 9 cm dilated.
HOSPITAL COURSE:
At the time of admission, patient received IV and was placed on a fetal monitor. Her water broke at 2 a.m. After 3 hours the patient delivered a baby boy with apgar scores of 8 at 1 minute and 10 at 5 minutes. Postpartum care was uneventful. The patient was discharged 2 days later.
INSTRUCTIONS TO PATIENT: Diet as tolerated. Tylenol every 4 hours for pain. She is to follow up in my office in 2 weeks.
Three ICD 10 codes needed________________________ _________________________ ____________________
SCIENCE
HEALTH SCIENCE
NURSING
