BOOK
Workbook for ICD-10-CM/PCS Coding: Theory and Practice, 2017 Edition - E-Book
(2016)
Additional Information
Book Details
Abstract
Use practical exercises to reinforce your understanding of facility-based ICD-10-CM and ICD-10-PCS coding! Corresponding to the chapters in Lovaasen’s ICD-10-CM/PCS Coding: Theory and Practice, 2017 Edition, this workbook lets you apply your coding knowledge to realistic medical records. This edition reflects the latest updates to ICD-10. Hundreds of engaging, interactive exercises help you review concepts, develop skills, and prepare for successful employment in medical coding.
- UPDATED coding examples and exercises let you practice with the latest ICD-10-CM/PCS codes.
- Hands-on activities and case studies help you master coding concepts and apply them to actual health records and real-world scenarios.
- Matching exercises, multiple-choice questions, coding questions, and case scenarios reinforce your understanding of key content in each chapter of the textbook.
- ICD-10 Official Guidelines for Coding and Reporting are provided in each coding chapter to enhance understanding of how to code accurately.
- Evolve companion website for the ICD-10-CM/PCS Coding textbook offers convenient online access to updates, partial answer keys, and coding guidelines.
- NEW Coding Medical and Surgical Procedures chapter is added to this edition.
- UPDATED content includes revisions to icd-10 code and coding guidelines, ensuring you have the latest coding information.
Table of Contents
| Section Title | Page | Action | Price |
|---|---|---|---|
| Front Cover | Cover | ||
| Inside Front Cover | ES2 | ||
| Workbook for ICD-10-CM/PCS Coding: Theory and Practice, 2017 Edition | i | ||
| Copyright | ii | ||
| Reviewers | iii | ||
| Contents | v | ||
| Chapter 1: The Rationale for and History of Coding | 1 | ||
| Abbreviations/Acronyms | 1 | ||
| Glossary Definitions | 1 | ||
| Multiple Choice | 1 | ||
| Chapter 2: The Health Record as the Foundation of Coding | 3 | ||
| Abbreviations/Acronyms | 3 | ||
| Glossary Definitions | 3 | ||
| Multiple Choice | 4 | ||
| Chapter 3: ICD-10-CM Format and Conventions | 7 | ||
| Abbreviations/Acronyms | 7 | ||
| Glossary Definitions | 7 | ||
| Multiple Choice | 7 | ||
| Short Answer | 8 | ||
| Chapter 4: Basic Steps of Coding | 11 | ||
| Abbreviations/Acronyms | 11 | ||
| Glossary Definitions | 11 | ||
| Coding | 11 | ||
| Multiple Choice | 12 | ||
| Chapter 5: General Coding Guidelines for Diagnosis | 13 | ||
| Abbreviations/Acronyms | 13 | ||
| Glossary Definitions | 13 | ||
| Coding | 14 | ||
| Chapter 6: Introduction to ICD-10-PCS | 15 | ||
| Abbreviations/Acronyms | 15 | ||
| Glossary Definitions | 15 | ||
| Multiple Choice/Short Answer | 16 | ||
| Chapter 7: General Coding Guidelines for Other Medical- and Surgical-Related Procedures and Ancillary Procedures | 19 | ||
| Abbreviations/Acronyms | 19 | ||
| Glossary Definitions | 19 | ||
| Multiple Choice/Short Answer | 19 | ||
| Coding | 21 | ||
| Chapter 8: Coding Medical and Surgical Procedures | 23 | ||
| Abbreviations/Acronyms | 23 | ||
| Glossary Definitions | 23 | ||
| Multiple Choice/Short Answer | 24 | ||
| Coding | 25 | ||
| Chapter 9: Symptoms, Signs, and Abnormal Clinical and Laboratory Findings Not Elsewhere Classified, and Z Codes (ICD-10-CM ... | 27 | ||
| Abbreviations/Acronyms | 27 | ||
| Glossary Definitions | 27 | ||
| Coding | 27 | ||
| Multiple Choice | 28 | ||
| Case Scenarios | 29 | ||
| Case Studies | 31 | ||
| 9-1. Csae Study | 31 | ||
| History and Physical | 31 | ||
| Physical Examination | 31 | ||
| Sigmoidoscopy Report | 32 | ||
| Discharge Summary | 32 | ||
| Diagnoses/Problems | 32 | ||
| Procedures | 32 | ||
| History, Major Findings, and Hospital Course | 32 | ||
| Discharge Medications | 32 | ||
| Discharge Instructions | 32 | ||
| Follow-up Care | 33 | ||
| Operative Report | 33 | ||
| Surgeon’s Narrative | 33 | ||
| Progress Note: OP Note | 33 | ||
| Csae Study Questions | 37 | ||
| 9-2. Csae Study | 38 | ||
| History and Physical | 38 | ||
| Physical Examination | 38 | ||
| Discharge Summary | 39 | ||
| Diagnoses/Problems | 39 | ||
| Procedures | 39 | ||
| History, Major Findings, and Hospital Course | 39 | ||
| Hospital Course by Systems | 40 | ||
| Discharge Medications | 41 | ||
| Follow-up Care | 41 | ||
| Progress Notes | 41 | ||
| Day 1 | 41 | ||
| Day 2 | 41 | ||
| Csae Study Questions | 41 | ||
| 9-3. Csae Study | 42 | ||
| History and Physical | 42 | ||
| Physical Examination | 42 | ||
| Discharge Summary | 43 | ||
| Diagnoses/Problems | 43 | ||
| Procedures | 43 | ||
| History, Major Findings, and Hospital Course | 43 | ||
| Discharge Medications | 44 | ||
| Follow-up Care | 44 | ||
| Brain Without IV Contrast, CT | 44 | ||
| Progress Notes | 44 | ||
| Day 1 | 44 | ||
| Day 2 | 44 | ||
| Csae Study Questions | 45 | ||
| Chapter 10: Certain Infectious and Parasitic Diseases (ICD-10-CM Chapter 1, Codes A00-B99) | 47 | ||
| Abbreviations/Acronyms | 47 | ||
| Glossary Definitions | 47 | ||
| Coding | 47 | ||
| Case Scenarios | 48 | ||
| Case Studies | 50 | ||
| 10-1. Csae Study | 50 | ||
| History and Physical | 50 | ||
| Physical Examination | 50 | ||
| Assessment/Plan | 50 | ||
| Discharge Summary | 50 | ||
| Diagnoses/Problems | 50 | ||
| History, Major Findings, and Hospital Course | 51 | ||
| Discharge Medications | 51 | ||
| Follow-up Care | 51 | ||
| Social Work Screening | 51 | ||
| Progress Notes | 51 | ||
| Day 1 | 51 | ||
| Day 2 | 51 | ||
| Day 3 | 51 | ||
| Csae Study Questions | 51 | ||
| 10-2. Csae Study | 52 | ||
| History and Physical | 52 | ||
| Physical Examination | 53 | ||
| Assessment/Plan | 53 | ||
| Discharge Summary | 53 | ||
| Diagnoses/Problems | 53 | ||
| Procedures | 54 | ||
| History, Major Findings, and Hospital Course | 54 | ||
| Assessment | 55 | ||
| Hospital Course/Plan | 55 | ||
| Discharge Medications | 55 | ||
| Discharge Instructions | 55 | ||
| Follow-up Care | 55 | ||
| Echocardiogram Report | 56 | ||
| Diagnostic Bronchoscopy | 56 | ||
| Diagnostic Bronchoscopy | 57 | ||
| Progress Notes | 58 | ||
| Day 1 | 58 | ||
| Day 2 | 58 | ||
| Day 3 | 58 | ||
| Day 4 | 58 | ||
| Day 5 | 58 | ||
| Csae Study Questions | 58 | ||
| 10-3. Csae Study | 59 | ||
| History and Physical | 59 | ||
| Physical Examination | 60 | ||
| Assessment/Plan | 60 | ||
| Discharge Summary | 61 | ||
| Diagnoses/Problems | 61 | ||
| Procedures | 61 | ||
| History, Major Findings, and Hospital Course | 61 | ||
| Physical Examination on Admission | 62 | ||
| Discharge Medications | 62 | ||
| Discharge Instructions | 63 | ||
| Follow-up Care | 63 | ||
| Progress Notes | 63 | ||
| Day 1 | 63 | ||
| Day 2 | 63 | ||
| Csae Study Questions | 63 | ||
| Chapter 11: Neoplasms (ICD-10-CM Chapter 2, Codes C00-D49) | 65 | ||
| Abbreviations/Acronyms | 65 | ||
| Glossary Definitions | 65 | ||
| Coding | 66 | ||
| Case Scenarios | 67 | ||
| Case Studies | 69 | ||
| 11-1. Csae Study | 69 | ||
| History and Physical | 69 | ||
| Review of Systems | 69 | ||
| Problems | 70 | ||
| Discharge Summary | 70 | ||
| Diagnoses/Problems | 70 | ||
| Procedures | 70 | ||
| History, Major Findings, and Hospital Course | 70 | ||
| Discharge Medications | 71 | ||
| Follow-up Care | 71 | ||
| Progress Notes | 71 | ||
| Day 1 | 71 | ||
| Day 2 | 71 | ||
| Csae Study Questions | 71 | ||
| 11-2. Csae Study | 72 | ||
| Clinic Note/Preoperative Evaluation | 72 | ||
| Diagnoses/Problems | 73 | ||
| Discharge Summary | 73 | ||
| Diagnoses/Problems: | 73 | ||
| History, Major Findings, and Hospital Course: | 73 | ||
| Discharge Medications | 74 | ||
| Follow-up Care | 74 | ||
| Operative Report | 74 | ||
| Surgeon’s Narrative | 74 | ||
| Progress Notes | 76 | ||
| Brief Op Note | 76 | ||
| Chapter 12: Diseases of the Blood and Blood-Forming Organs and Certain Disorders Involving the Immune Mechanism (ICD-10-CM ... | 83 | ||
| Abbreviations/Acronyms | 83 | ||
| Glossary Definitions | 83 | ||
| Coding | 84 | ||
| Case Scenarios | 85 | ||
| Case Studies | 86 | ||
| 12-1. Csae Study | 86 | ||
| History and Physical | 86 | ||
| Physical Examination | 87 | ||
| Discharge Summary | 87 | ||
| Diagnoses/Problems | 87 | ||
| Procedures | 87 | ||
| History, Major Findings, and Hospital Course | 87 | ||
| Hospital Course | 87 | ||
| Discharge Medications | 88 | ||
| Progress Notes | 88 | ||
| Day 1 | 88 | ||
| Day 2 | 88 | ||
| Day 3 | 88 | ||
| Csae Study Questions | 88 | ||
| 12-2. Csae Study | 89 | ||
| Clinic Note | 89 | ||
| Major Findings | 89 | ||
| Physical Examination: | 89 | ||
| Assessments | 90 | ||
| History and Physical | 90 | ||
| Physical Examination | 91 | ||
| Operative Report | 91 | ||
| Surgeon’s Narrative | 92 | ||
| Discharge Summary | 92 | ||
| Diagnoses/Problems | 92 | ||
| Procedure | 92 | ||
| History, Major Findings, and Hospital Course | 92 | ||
| Discharge Medications | 93 | ||
| Discharge Instructions | 93 | ||
| Progress Notes | 93 | ||
| Day 1 | 93 | ||
| Day 2 | 93 | ||
| Csae Study Questions | 94 | ||
| Chapter 13: Endocrine, Nutritional, and Metabolic Diseases (ICD-10-CM Chapter 4,Codes E00-E89) | 95 | ||
| Abbreviations/Acronyms | 95 | ||
| Glossary Definitions | 95 | ||
| Coding | 96 | ||
| Case Scenarios | 97 | ||
| Case Studies | 99 | ||
| 13-1. Csae Study | 99 | ||
| History and Physical | 99 | ||
| Physical Examination | 99 | ||
| Assessment and Plan | 99 | ||
| Discharge Summary | 99 | ||
| Diagnoses/Problems | 99 | ||
| Procedures | 100 | ||
| History, Major Findings, and Hospital Course | 100 | ||
| Physical Examination | 100 | ||
| Hospital Course by System | 101 | ||
| Discharge Medications | 101 | ||
| Follow-up Care | 101 | ||
| Contrast CT | 101 | ||
| Chest, Abdomen, and Pelvis: | 101 | ||
| Progress Notes | 102 | ||
| Day | 102 | ||
| Day 1 | 102 | ||
| Csae Study Questions | 102 | ||
| 13-2. Csae Study | 103 | ||
| History and Physical | 103 | ||
| Physical Examination | 104 | ||
| Discharge Summary | 104 | ||
| Diagnoses/Problems | 104 | ||
| Procedure | 104 | ||
| History, Major Findings, and Hospital Course | 104 | ||
| Discharge Medications | 105 | ||
| Discharge Instructions | 105 | ||
| Follow-up Care | 105 | ||
| Operative Report | 105 | ||
| Surgeon’s Narrative | 105 | ||
| Path Report | 106 | ||
| Progress Notes | 106 | ||
| Brief Operative Note | 106 | ||
| Day 1 | 107 | ||
| Day 2 | 107 | ||
| Day 3 | 107 | ||
| Csae Study Questions | 107 | ||
| 13-3. Csae Study | 108 | ||
| History and Physical | 108 | ||
| Chapter 14: Mental, Behavioral, and Neurodevelopmental Disorders (ICD-10-CM Chapter 5, Codes F01-F99) | 123 | ||
| Abbreviations/Acronyms | 123 | ||
| Glossary Definitions | 123 | ||
| Coding | 124 | ||
| Case Scenarios | 125 | ||
| 127 Case Studies | 127 | ||
| 14-1. Csae Study | 127 | ||
| History and Physical | 127 | ||
| Discharge Summary | 127 | ||
| Diagnoses/Problems | 127 | ||
| Procedures | 127 | ||
| History, Major Findings, and Hospital Course | 128 | ||
| Follow-up Care | 128 | ||
| Chest | 128 | ||
| Brain Without IV Contrast, CT | 128 | ||
| Results | 128 | ||
| CT C-spine Without Contrast, Complex | 129 | ||
| Progress Notes | 129 | ||
| Day 1 | 129 | ||
| Day 2 | 129 | ||
| Csae Study Questions | 129 | ||
| 14-2. Csae Study | 131 | ||
| History and Physical | 131 | ||
| Discharge Summary | 131 | ||
| Progress Notes | 132 | ||
| Day 1 | 132 | ||
| Day 2 | 132 | ||
| Day 3 | 132 | ||
| Csae Study Questions | 132 | ||
| Chapter 15: Diseases of the Nervous System, Diseases of the Eye and Adnexa, and Diseases of the Ear and Mastoid Process (I ... | 135 | ||
| Abbreviations/Acronyms | 135 | ||
| Glossary Definitions | 135 | ||
| Coding | 136 | ||
| Case Scenarios | 136 | ||
| Case Studies | 138 | ||
| 15-1. Csae Study | 138 | ||
| History and Physical | 138 | ||
| Review of Systems | 138 | ||
| Discharge Summary | 139 | ||
| Diagnoses/Problems | 139 | ||
| Procedures | 139 | ||
| History, Major Findings, and Hospital Course | 139 | ||
| Report of Electroencephalogram | 140 | ||
| Progress Notes | 141 | ||
| Day 1 | 141 | ||
| Day 2 | 141 | ||
| Day 3 | 141 | ||
| Csae Study Questions | 141 | ||
| 15-2. Csae Study | 142 | ||
| History and Physical | 142 | ||
| Review of Systems | 143 | ||
| Physical Examination | 143 | ||
| Discharge Summary | 144 | ||
| Diagnoses/Problems | 144 | ||
| Procedures | 144 | ||
| History, Major Findings, and Hospital Course | 144 | ||
| Discharge Instructions | 145 | ||
| Follow-up Care | 145 | ||
| MRI, Brain With and Without Contrast With Diff | 145 | ||
| Brain Without IV Contrast CT | 146 | ||
| Progress Notes | 146 | ||
| Day 1 | 146 | ||
| Day 2 | 146 | ||
| Csae Study Questions | 147 | ||
| 15-3. Csae Study | 148 | ||
| Admission History and Physical Examination | 148 | ||
| Physical Examination | 148 | ||
| Discharge Summary | 149 | ||
| Diagnoses/Problems | 149 | ||
| Procedures | 149 | ||
| History, Major Findings, and Hospital Course | 149 | ||
| Discharge Instructions | 150 | ||
| Follow-up Care | 150 | ||
| Procedure Note | 150 | ||
| Day 1 | 150 | ||
| Day 2 | 150 | ||
| Day 3 | 151 | ||
| Day 4 | 151 | ||
| Csae Study Questions | 151 | ||
| Chapter 16: Diseases of the Circulatory System (ICD-10-CM Chapter 9, Codes I00-I99) | 153 | ||
| Abbreviations/Acronyms | 153 | ||
| Glossary Definitions | 153 | ||
| Coding | 154 | ||
| Case Scenarios | 154 | ||
| Case Studies | 156 | ||
| 16-1. Csae Study | 156 | ||
| History and Physical | 156 | ||
| Physical Examination | 156 | ||
| Assessment/Plan | 157 | ||
| Discharge Summary | 157 | ||
| Diagnoses/Problems | 157 | ||
| Procedures | 157 | ||
| History, Major Findings, and Hospital Course | 157 | ||
| Discharge Medications | 158 | ||
| Discharge Instructions | 158 | ||
| Follow-up Care | 158 | ||
| Electrocardiogram Report | 158 | ||
| Transthoracic Echocardiogram | 158 | ||
| Chest AP Portable | 159 | ||
| Thoracic CT | 159 | ||
| Progress Notes | 160 | ||
| Day 1 | 160 | ||
| Day 2 | 160 | ||
| Day 3 | 160 | ||
| Day 4 | 160 | ||
| Csae Study Questions | 160 | ||
| 16-2. Csae Study | 161 | ||
| History and Physical | 161 | ||
| Review of Systems | 161 | ||
| Physical Examination | 162 | ||
| Assessment/Plan | 162 | ||
| Procedures Performed | 162 | ||
| Past Medical History | 162 | ||
| Procedure Description | 163 | ||
| Impression | 163 | ||
| Recommendations | 164 | ||
| Procedure Data | 164 | ||
| Case Medications | 164 | ||
| Vital Signs | 164 | ||
| EPS/Ablation Methods | 164 | ||
| Anesthesia | 164 | ||
| Vascular Access | 165 | ||
| Chapter 17: Diseases of the Respiratory System (ICD-10-CM Chapter 10, Codes J00-J99) | 177 | ||
| Abbreviations/Acronyms | 177 | ||
| Glossary Definitions | 177 | ||
| Coding | 178 | ||
| Case Scenarios | 179 | ||
| Case Studies | 181 | ||
| 17-1. Csae Study | 181 | ||
| Admission History and Physical | 181 | ||
| Thoracic CT With Contrast | 182 | ||
| Result | 182 | ||
| Discharge Summary | 182 | ||
| Diagnoses/Problems | 182 | ||
| History, Major Findings, and Hospital Course | 183 | ||
| Discharge Medications | 183 | ||
| Discharge Instructions | 183 | ||
| Follow-up Care | 184 | ||
| Progress Notes | 184 | ||
| Day 1 | 184 | ||
| Day 2 | 184 | ||
| Day 3 | 184 | ||
| Oncology Consultation | 184 | ||
| Csae Study Questions | 185 | ||
| 17-2. Csae Study | 186 | ||
| History and Physical | 186 | ||
| Physical Examination | 186 | ||
| Discharge Summary | 187 | ||
| Diagnoses/Problems | 187 | ||
| Procedures | 187 | ||
| History, Major Findings, and Hospital Course | 187 | ||
| Discharge Medications | 188 | ||
| Follow-up Care | 188 | ||
| Progress Notes | 188 | ||
| Day 1 | 188 | ||
| Day 2 | 189 | ||
| Day 3 | 189 | ||
| Csae Study Questions | 189 | ||
| 17-3 Csae Study | 190 | ||
| History and Physical | 190 | ||
| Discharge Summary | 191 | ||
| Diagnoses/Problems | 191 | ||
| Procedures | 191 | ||
| History, Major Findings, and Hospital Course | 191 | ||
| Discharge Medications | 192 | ||
| Discharge Instructions | 192 | ||
| Follow-up Care | 192 | ||
| Progress Notes | 192 | ||
| Day 1 | 192 | ||
| Day 2 | 193 | ||
| Day 3 | 193 | ||
| Day 4 | 193 | ||
| Csae Study Questions | 193 | ||
| Chapter 18: Diseases of the Digestive System (ICD-10-CM Chapter 11, Codes K00-K95) | 195 | ||
| Abbreviations/Acronyms | 195 | ||
| Glossary Definitions | 195 | ||
| Coding | 196 | ||
| Case Scenarios | 196 | ||
| Case Studies | 198 | ||
| 18-1. Csae Study | 198 | ||
| History and Physical | 198 | ||
| Discharge Summary | 199 | ||
| Diagnoses/Problems | 199 | ||
| Procedures | 199 | ||
| History, Major Findings, and Hospital Course | 199 | ||
| Progress Notes | 199 | ||
| Day 1 | 199 | ||
| Day 2 | 200 | ||
| Csae Study Question | 200 | ||
| 18-2. Csae Study | 201 | ||
| History and Physical | 201 | ||
| Discharge Summary | 202 | ||
| Procedures | 202 | ||
| History, Major Findings, and Hospital Course | 202 | ||
| Stomach/Pylorus | 202 | ||
| Upper GI Series | 202 | ||
| Progress Notes | 203 | ||
| Day 1 | 203 | ||
| Day 2 | 203 | ||
| Day 3 | 203 | ||
| Csae Study Question | 203 | ||
| 18-2. Csae Study | 204 | ||
| History and Physical | 204 | ||
| Review of Systems | 205 | ||
| Discharge Summary | 205 | ||
| Diagnoses/Problems | 205 | ||
| Procedures | 206 | ||
| History, Major Findings, and Hospital Course | 206 | ||
| Discharge Instructions | 207 | ||
| Follow-up Care | 208 | ||
| Abdominal and Pelvic CT Without Contrast | 208 | ||
| Progress Notes | 208 | ||
| Day 1 | 208 | ||
| Day 2 | 208 | ||
| Day 3 | 208 | ||
| Day 4 | 208 | ||
| Day 5 | 208 | ||
| Day 6 | 208 | ||
| Csae Study Questions | 209 | ||
| Chapter 19: Diseases of the Skin and Subcutaneous Tissue (ICD-10-CM Chapter 12, Codes L00-L99) | 211 | ||
| Abbreviations/Acronyms | 211 | ||
| Glossary Definitions | 211 | ||
| Coding | 211 | ||
| Case Scenarios | 212 | ||
| Case Studies | 213 | ||
| 19-1. Csae Study | 213 | ||
| History and Physical | 213 | ||
| Review of Systems | 214 | ||
| Physical Examination | 214 | ||
| Inpatient Dermatology Consultation Note | 215 | ||
| Discharge Summary | 215 | ||
| Diagnoses/Problems | 215 | ||
| Procedures | 216 | ||
| History, Major Findings, and Hospital Course | 216 | ||
| Discharge Instructions | 217 | ||
| Follow-up Care | 217 | ||
| Wound Care Specialist | 217 | ||
| Progress Notes | 217 | ||
| Day 1 | 217 | ||
| Day 2 | 217 | ||
| Day 3 | 217 | ||
| Day 4 | 218 | ||
| Csae Study Questions | 218 | ||
| 19-2. Csae Study | 219 | ||
| History and Physical | 219 | ||
| Discharge Summary | 220 | ||
| Procedures | 220 | ||
| History, Major Findings, and Hospital Course | 220 | ||
| Hospital Course by Symptoms | 220 | ||
| Follow-up Care | 221 | ||
| Wound Care Specialist | 221 | ||
| Final Report | 221 | ||
| Progress Notes | 221 | ||
| Day 1 | 221 | ||
| Day 2 | 221 | ||
| Day 3 | 222 | ||
| Csae Study Questions | 222 | ||
| Chapter 20: Diseases of the Musculoskeletal System and Connective Tissue (ICD-10-CM Chapter 13, Codes M00-M99) | 223 | ||
| Abbreviations/Acronyms | 223 | ||
| Glossary Definitions | 223 | ||
| Coding | 224 | ||
| Case Scenarios | 225 | ||
| Case Studies | 227 | ||
| 20-1. Csae Study | 227 | ||
| History and Physical | 227 | ||
| Physical Examination | 227 | ||
| Podiatry Consult | 228 | ||
| Diagnosis | 228 | ||
| X-ray: Foot, Left | 229 | ||
| MRI, Left Lower Extremity | 229 | ||
| Discharge Summary | 229 | ||
| Diagnoses/Problems | 229 | ||
| Procedures | 229 | ||
| History, Major Findings, and Hospital Course | 230 | ||
| Discharge Instructions | 230 | ||
| Follow-up Care | 230 | ||
| Progress Notes | 230 | ||
| Day 1 | 230 | ||
| Day 2 | 230 | ||
| Day 3 | 230 | ||
| Csae Study Questions | 231 | ||
| 20-2. Csae Study | 232 | ||
| Clinic Note/Preop Evaluation | 232 | ||
| Discharge Summary | 232 | ||
| Diagnoses/Problems | 232 | ||
| Procedures | 233 | ||
| History, Major Findings, and Hospital Course | 233 | ||
| Discharge Instructions | 233 | ||
| Operative Report | 233 | ||
| Surgeon’s Narrative | 233 | ||
| Shoulder X-ray | 235 | ||
| Csae Study Questions | 239 | ||
| 20-3. Csae Study | 240 | ||
| Clinic Note/Preop Evaluation | 240 | ||
| Discharge Summary | 240 | ||
| Diagnoses/Problems | 240 | ||
| Procedures | 241 | ||
| History, Major Findings, and Hospital Course | 241 | ||
| Discharge Instructions | 241 | ||
| Follow-up Care | 241 | ||
| Operative Report | 241 | ||
| Surgeon’s Narrative | 242 | ||
| Lumbar Spine Port in OR | 243 | ||
| CT Left Spine Without Contrast Complex | 243 | ||
| Progress Notes | 244 | ||
| Postop Note | 244 | ||
| Day 1 | 244 | ||
| Day 2 | 245 | ||
| Day 3 | 245 | ||
| Csae Study Questions | 245 | ||
| Chapter 21: Diseases of the Genitourinary System (ICD-10-CM Chapter 14, Codes N00-N99) | 247 | ||
| Abbreviations/Acronyms | 247 | ||
| Glossary Definitions | 247 | ||
| Coding | 248 | ||
| Case Scenarios | 249 | ||
| Case Studies | 251 | ||
| 21-1. Case Study | 251 | ||
| Clinic Note/Preop Evaluation | 251 | ||
| Problems/Diagnoses | 252 | ||
| Plans | 252 | ||
| Discharge Summary | 252 | ||
| Diagnoses/Problems | 252 | ||
| Procedures | 252 | ||
| History, Major Findings, and Hospital Course | 252 | ||
| Discharge Medications | 252 | ||
| Discharge Instructions | 253 | ||
| Follow-up Care | 253 | ||
| Operative Report | 253 | ||
| Surgeon’s Narrative | 253 | ||
| Progress Notes | 254 | ||
| Transplant Surgery Note | 254 | ||
| Day 1 | 254 | ||
| Day 2 | 254 | ||
| Case Study Questions | 254 | ||
| 21-2. Case Study | 255 | ||
| History and Physical | 255 | ||
| Review of Systems | 256 | ||
| Physical Examination | 256 | ||
| Discharge Summary | 256 | ||
| Diagnoses/Problems | 256 | ||
| Procedures | 256 | ||
| History, Major Findings, and Hospital Course | 257 | ||
| Hospital Course by Systems | 257 | ||
| Discharge Medications | 258 | ||
| Follow-up Care | 258 | ||
| Progress Note | 258 | ||
| Day 1 | 258 | ||
| Day 2 | 258 | ||
| Day 3 | 258 | ||
| Day 4 | 258 | ||
| DNR/DNI Discussion | 258 | ||
| Day 5 | 259 | ||
| Case Study Questions | 259 | ||
| 21-3. Case Study | 260 | ||
| History and Physical | 260 | ||
| Review of Systems | 260 | ||
| Physical Examination | 260 | ||
| Discharge Summary | 261 | ||
| Diagnoses/Problems | 261 | ||
| Procedures | 261 | ||
| History, Major Findings, and Hospital Course | 261 | ||
| Discharge Medications | 262 | ||
| Discharge Instructions | 262 | ||
| Follow-up Care | 262 | ||
| Progress Notes | 262 | ||
| Day 1 | 262 | ||
| Day 2 | 262 | ||
| Case Study Questions | 263 | ||
| Chapter 22: Pregnancy, Childbirth, and the Puerperium (ICD-10-CM Chapter 15, Codes O00-O9A) | 265 | ||
| Abbreviations/Acronyms | 265 | ||
| Glossary Definitions | 265 | ||
| Coding | 265 | ||
| Case Scenarios | 266 | ||
| Case Studies | 267 | ||
| 22-1. Case Study | 267 | ||
| History and Physical | 267 | ||
| OB Delivery Summary | 268 | ||
| Membranes Monitoring | 269 | ||
| Delivery Information | 269 | ||
| Episiotomy/Laceration Information | 269 | ||
| Delivery Diagnosis | 270 | ||
| Delivery Procedures | 270 | ||
| Discharge Summary | 270 | ||
| Procedures: | 270 | ||
| History, Major Findings, and Hospital Course | 271 | ||
| Discharge Instructions | 272 | ||
| Follow-up Care | 272 | ||
| Progress Notes | 272 | ||
| Day 1 | 272 | ||
| Day 2 | 272 | ||
| Case Study Questions | 272 | ||
| 22-2. Case Study | 273 | ||
| History and Physical | 273 | ||
| Physical Examination | 273 | ||
| OB/Delivery Summary | 274 | ||
| Membranes/Monitoring | 274 | ||
| Delivery Information | 274 | ||
| Delivery/Diagnosis | 275 | ||
| Delivery Procedures | 275 | ||
| Discharge Summary | 275 | ||
| Diagnoses/Problems | 275 | ||
| Procedures | 275 | ||
| History, Major Findings, and Hospital Course | 276 | ||
| Discharge Instructions | 277 | ||
| Follow-up Care | 277 | ||
| Operative Report | 277 | ||
| Surgeon’s Narrative | 277 | ||
| Operative Report | 278 | ||
| Surgeon’s Narrative | 278 | ||
| Progress Notes | 279 | ||
| Day 1 | 279 | ||
| Day 2 | 279 | ||
| Day 3 | 279 | ||
| Day 4 | 279 | ||
| Day 5 | 280 | ||
| Day 6 | 280 | ||
| Case Study Questions | 280 | ||
| 22-3. Case Study | 281 | ||
| History and Physical | 281 | ||
| Discharge Summary | 281 | ||
| Diagnoses/Problems | 281 | ||
| Procedures | 282 | ||
| History, Major Findings, and Hospital Course | 282 | ||
| Discharge Instructions | 283 | ||
| Follow-up Care | 283 | ||
| Ultrasound Examination | 283 | ||
| Examination Indications | 283 | ||
| General Results | 283 | ||
| Fetal Doppler Studies | 283 | ||
| Social Work Progress Note | 284 | ||
| Progress Notes | 284 | ||
| Day 1 | 284 | ||
| Day 2 | 284 | ||
| Day 3 | 285 | ||
| Day 4 | 285 | ||
| Day 5 | 285 | ||
| Day 6 | 285 | ||
| Day 7 | 285 | ||
| Day 8 | 285 | ||
| Case Study Questions | 285 | ||
| Chapter 23: Certain Conditions Originating in the Perinatal Period and Congenital Malformations, Deformations, and Chromos ... | 287 | ||
| Chapter 24: Injury and Certain Other Consequences of External Causes and External Causes of Morbidity (ICD-10-CM Chapter 1 ... | 299 | ||
| Abbreviations/Acronyms | 287 | ||
| Glossary Definitions | 287 | ||
| Coding | 287 | ||
| Case Scenarios | 288 | ||
| Case Studies | 289 | ||
| 23-1. Case Study | 289 | ||
| History and Physical Examination | 289 | ||
| Discharge Summary | 290 | ||
| Procedures | 290 | ||
| History, Major Findings, and Hospital Course | 290 | ||
| Angio Carotid Cerebral Bilat | 290 | ||
| Progress Note | 291 | ||
| Case Study Questions | 291 | ||
| 23-2. Case Study | 292 | ||
| Admission Examination | 292 | ||
| Discharge Examination | 293 | ||
| Circumcision Note | 293 | ||
| Discharge Summary | 293 | ||
| Diagnoses/Problems | 293 | ||
| Procedures | 293 | ||
| History, Major Findings, and Hospital Course | 293 | ||
| Discharge Instructions | 294 | ||
| Follow-up Care | 294 | ||
| Case Study Questions | 294 | ||
| 23-3. Case Study | 295 | ||
| Admission Examination | 295 | ||
| Discharge Examination | 295 | ||
| Discharge Summary | 295 | ||
| Diagnoses/Problems | 295 | ||
| Procedures | 295 | ||
| History, Major Findings, and Hospital Course | 296 | ||
| Discharge Instructions | 296 | ||
| Follow-up Care | 296 | ||
| Case Study Questions | 296 | ||
| Abbreviations/Acronyms | 299 | ||
| Glossary Definitions | 299 | ||
| Coding | 300 | ||
| Case Scenarios | 301 | ||
| Case Studies | 303 | ||
| 24-1. Case Study | 303 | ||
| History and Physical | 303 | ||
| Discharge Summary | 303 | ||
| Diagnoses/Problems | 303 | ||
| Procedures | 303 | ||
| History, Major Findings, and Hospital Course | 303 | ||
| Discharge Instructions | 304 | ||
| Follow-up Care | 304 | ||
| Brain Without IV Contrast CT | 304 | ||
| CT of the Maxillofacial Bones With Contrast | 304 | ||
| CT of Cervical Spine Without Contrast | 304 | ||
| Progress Note | 305 | ||
| Case Study Questions | 305 | ||
| 24.2. Case Study | 306 | ||
| History and Physical | 306 | ||
| Operative Report | 306 | ||
| Surgeon’s Narrative | 307 | ||
| Discharge Summary | 308 | ||
| Diagnoses/Problems | 308 | ||
| Procedures | 308 | ||
| History, Major Findings, and Hospital Course | 308 | ||
| Discharge Instructions | 309 | ||
| Follow-up Care | 309 | ||
| Pelvis and Hip, Right | 309 | ||
| Tibia and Fibula, Right | 309 | ||
| Progress Notes | 309 | ||
| Day 1 | 309 | ||
| Day 2 | 309 | ||
| Day 3 | 310 | ||
| Day 4 | 310 | ||
| Case Study Questions | 310 | ||
| 24-3. Case Study | 311 | ||
| History and Physical | 311 | ||
| Discharge Summary | 311 | ||
| Diagnoses/Problems | 311 | ||
| Procedures | 312 | ||
| History, Major Findings, and Hospital Course | 312 | ||
| Progress Note | 312 | ||
| Case Study Questions | 312 | ||
| Chapter 25: Burns, Adverse Effects, and Poisonings (ICD-10-CM Chapters 19 and 20,Codes S00-Y99) | 315 | ||
| Abbreviations/Acronyms | 315 | ||
| Glossary Definitions | 315 | ||
| Coding | 316 | ||
| Case Scenarios | 317 | ||
| Case Studies | 319 | ||
| 25-1. Case Study | 319 | ||
| History and Physical | 319 | ||
| Discharge Summary | 320 | ||
| Diagnoses/Problems | 320 | ||
| Procedures | 320 | ||
| History, Major Findings, and Hospital Course | 320 | ||
| Progress Note | 320 | ||
| Case Study Questions | 320 | ||
| 25-2. Case Study | 321 | ||
| Clinic Note/History and Physical | 321 | ||
| Discharge Summary | 322 | ||
| Diagnoses/Problems | 322 | ||
| Procedures | 322 | ||
| History, Major Findings, and Hospital Course | 322 | ||
| Hospital Course by System | 323 | ||
| Chest PA and Lateral | 324 | ||
| Progress Note | 324 | ||
| Case Study Questions | 324 | ||
| 25-3. Case Study | 325 | ||
| History and Physical | 325 | ||
| Discharge Summary | 326 | ||
| Diagnoses/Problems | 326 | ||
| Procedures | 326 | ||
| History, Major Findings, and Hospital Course | 326 | ||
| Hospital Course by System | 327 | ||
| Discharge Instructions | 327 | ||
| Follow-up Care | 327 | ||
| Progress Notes | 327 | ||
| Day 1 | 327 | ||
| Day 2 | 328 | ||
| Case Study Questions | 328 | ||
| Chapter 26: Complications of Surgical and Medical Care | 329 | ||
| Abbreviations/Acronyms | 329 | ||
| Glossary Definitions | 329 | ||
| Coding | 329 | ||
| Case Scenarios | 330 | ||
| Case Studies | 331 | ||
| 26-1. Case Study | 331 | ||
| History and Physical | 331 | ||
| Review of Systems | 332 | ||
| Physical Examination | 332 | ||
| Discharge Summary | 332 | ||
| Diagnoses/Problems | 332 | ||
| Procedures | 332 | ||
| History, Major Findings, and Hospital Course | 332 | ||
| Progress Notes | 333 | ||
| Day 1 | 333 | ||
| Day 2 | 333 | ||
| Case Study Questions | 333 | ||
| 26-2. Case Study | 334 | ||
| History and Physical | 334 | ||
| Discharge Summary | 335 | ||
| Diagnoses/Problems | 335 | ||
| Procedures | 335 | ||
| History, Major Findings, and Hospital Course | 335 | ||
| Discharge Instructions | 336 | ||
| Follow-up Care | 336 | ||
| Abscess Drain Cath. Placement | 336 | ||
| CT Abd and Pelvis With Contrast | 337 | ||
| Progress Notes | 337 | ||
| Day 1 | 337 | ||
| Day 2 | 337 | ||
| Day 3 | 337 | ||
| Day 4 | 337 | ||
| Case Study Questions | 338 | ||
| 26-3. Case Study | 339 | ||
| History and Physical | 339 | ||
| Discharge Summary | 340 | ||
| Diagnoses/Problems | 340 | ||
| Procedures | 340 | ||
| History, Major Findings, and Hospital Course | 340 | ||
| Discharge Instructions | 341 | ||
| Follow-up Care | 341 | ||
| Pediatric Inpatient Hematology Consultation | 341 | ||
| Duplex Scan, Ven lt Low Ext | 343 | ||
| Ultrasound, Single Quad | 343 | ||
| Mechanical Thrombolysis | 343 | ||
| Angio: Infusion/embolized | 344 | ||
| Progress Notes | 345 | ||
| Day 1 | 345 | ||
| Day 2 | 345 | ||
| Day 3 | 345 | ||
| Day 4 | 345 | ||
| Case Study Questions | 346 | ||
| Additional Practice Exercises | 347 | ||
| Case Scenarios | 347 | ||
| Home Health | 347 | ||
| Case Scenarios | 348 | ||
| Mental Health | 348 | ||
| Case Scenarios | 349 | ||
| Rehabilitation/Nursing Home | 349 | ||
| Case Scenarios | 350 | ||
| Case Studies | 353 | ||
| 18. Case Study | 353 | ||
| Title of Operation | 353 | ||
| Indications for Surgery | 353 | ||
| Preoperative Diagnosis | 353 | ||
| Postoperative Diagnosis | 353 | ||
| Anesthesia | 353 | ||
| Prosthetic Device/Implant | 353 | ||
| Surgeons Narrative | 353 | ||
| 19. Case Study | 354 | ||
| Title of Operation | 354 | ||
| Indications for Surgery | 354 | ||
| Preoperative Diagnosis | 354 | ||
| Postoperative Diagnosis | 354 | ||
| Anesthesia | 354 | ||
| Prosthetic Device/Implant | 354 | ||
| Surgeon's Narrative | 354 | ||
| 20. Case Study | 355 | ||
| Title of Operation | 355 | ||
| Indications for Surgery | 355 | ||
| Preoperative Diagnosis | 355 | ||
| Postoperative Diagnosis | 355 | ||
| Surgeon's Narrative | 355 | ||
| 21. Case Study | 356 | ||
| Title of Operation | 356 | ||
| Indications for Surgery | 356 | ||
| Preoperative Diagnosis | 356 | ||
| Postoperative Diagnosis | 356 | ||
| Anesthesia | 356 | ||
| Specimen (Bacteriologic, Pathologic, or Other) | 356 | ||
| Surgeon's Narrative | 357 | ||
| 22. Case Study | 357 | ||
| Title of Operation | 357 | ||
| Indications for Surgery | 357 | ||
| Preoperative Diagnosis | 357 | ||
| Postoperative Diagnosis | 357 | ||
| Anesthesia | 358 | ||
| Specimen (Bacteriologic, Pathologic, or Other) | 358 | ||
| Surgeon's Narrative | 358 | ||
| 23. Case Study | 359 | ||
| Title of Operation | 359 | ||
| Indications for Surgery | 359 | ||
| Preoperative Diagnosis | 359 | ||
| Postoperative Diagnosis | 359 | ||
| Anesthesia | 359 | ||
| Specimen (Bacteriologic, Pathologic, or Other) | 359 | ||
| Prosthetic Device/Implant | 359 | ||
| Pathology | 360 | ||
| Cultures | 360 | ||
| Drain | 360 | ||
| Surgeon's Narrative | 360 | ||
| 24. Case Study | 361 | ||
| Title of Operation | 361 | ||
| Indications for Surgery | 361 | ||
| Preoperative Diagnosis | 361 | ||
| Postoperative Diagnosis | 361 | ||
| Anesthesia | 361 | ||
| Specimen (Bacteriologic, Pathologic, or Other) | 361 | ||
| Prosthetic Device/Implant | 361 | ||
| Surgeon's Narrative | 361 | ||
| 25. Case Study | 362 | ||
| Title of Operation | 362 | ||
| Indications for Surgery | 362 | ||
| Preoperative Diagnosis | 362 | ||
| Postoperative Diagnosis | 362 | ||
| Surgeon's Narrative | 362 | ||
| 26. Case Study | 363 | ||
| Title of Operation | 363 | ||
| Indications for Surgery | 363 | ||
| Preoperative Diagnosis | 363 | ||
| Postoperative Diagnosis | 363 | ||
| Surgeon's Narrative | 363 | ||
| 27. Case Study | 364 | ||
| Title of Operation | 364 | ||
| Indications for Surgery | 364 | ||
| Preoperative Diagnosis | 364 | ||
| Postoperative Diagnosis | 364 | ||
| Anesthesia | 364 | ||
| Specimen (Bacteriologic, Pathologic, or Other) | 364 | ||
| Prosthetic Device/Implant | 364 | ||
| Surgeon's Narrative | 364 | ||
| 28. Case Study | 365 | ||
| Title of Operation | 365 | ||
| Preoperative Diagnosis | 365 | ||
| Postoperative Diagnosis | 365 | ||
| Anesthesia | 365 | ||
| Surgeon's Narrative | 365 | ||
| 29. Case Study | 366 | ||
| Title of Operation | 366 | ||
| Indications for Surgery | 366 | ||
| Preoperative Diagnosis | 366 | ||
| Postoperative Diagnosis | 366 | ||
| Anesthesia | 366 | ||
| Prosthetic Device/Implant | 366 | ||
| Surgeon's Narrative | 366 | ||
| 30. Case Study | 368 | ||
| Title of Operation | 368 | ||
| Indications for Surgery | 368 | ||
| Preoperative Diagnosis | 368 | ||
| Postoperative Diagnosis | 368 | ||
| Anesthesia | 368 | ||
| Specimen (Bacteriologic, Pathologic, and Other) | 368 | ||
| Prosthetic Device/Implant | 368 | ||
| Surgeon's Narrative | 368 | ||
| 31. Case Study | 369 | ||
| Title of Operation | 369 | ||
| Indications for Surgery | 369 | ||
| Preoperative Diagnosis | 369 | ||
| Postoperative Diagnosis | 369 | ||
| Anesthesia | 369 | ||
| Specimen (Bacteriologic, Pathologic, or Other) | 369 | ||
| Surgeon's Narrative | 369 | ||
| 32. Case Study | 370 | ||
| Title of Operation | 370 | ||
| Preoperative Diagnosis | 370 | ||
| Postoperative Diagnosis | 370 | ||
| Surgeon's Narrative | 370 | ||
| 33. Case Study | 371 | ||
| Title of Operation | 371 | ||
| Indications for Surgery | 371 | ||
| Preoperative Diagnosis | 371 | ||
| Postoperative Diagnosis | 371 | ||
| Anesthesia | 371 | ||
| Specimen (Bacteriologic, Pathologic, or Other) | 371 | ||
| Surgeon's Narrative | 371 | ||
| 34. Case Study | 373 | ||
| Title of Operation | 373 | ||
| Indications for Surgery | 373 | ||
| Preoperative Diagnosis | 373 | ||
| Postoperative Diagnosis | 373 | ||
| Anesthesia | 373 | ||
| Specimen (Bacteriologic, Pathologic, or Other) | 373 | ||
| Surgeon's Narrative | 373 | ||
| 35. Case Study | 374 | ||
| Title of Operation | 374 | ||
| Indications for Surgery | 374 | ||
| Preoperative Diagnosis | 374 | ||
| Postoperative Diagnosis | 374 | ||
| Anesthesia | 374 | ||
| Specimen (Bacteriologic, Pathologic, or Other) | 375 | ||
| Surgeon's Narrative | 375 | ||
| 36. Case Study | 376 | ||
| Title of Operation | 376 | ||
| Indications for Surgery | 376 | ||
| Preoperative Diagnosis | 376 | ||
| Postoperative Diagnosis | 376 | ||
| Anesthesia | 376 | ||
| Specimen (Bacteriologic, Pathologic, or Other) | 376 | ||
| Prosthetic Device/Implant | 376 | ||
| Surgeon's Narrative | 376 | ||
| 37. Case Study | 377 | ||
| Electrophysiology Procedure Report | 377 | ||
| Procedure Performed | 377 | ||
| History | 377 | ||
| Procedure Description | 378 | ||
| Complications | 378 | ||
| Procedure Data | 379 | ||
| Case Medications | 379 | ||
| Contrast | 379 | ||
| Vital Signs | 379 | ||
| Devices | 379 | ||
| Generator | 379 | ||
| Lead | 379 | ||
| Upper Extremity Venogram | 379 | ||
| Vascular Access | 379 | ||
| Guidance Methods, Needles, and Wires | 380 | ||
| PPM/ICD System Revision | 380 | ||
| Indication(s) | 380 | ||
| Summary Findings | 380 | ||
| Revision Procedures (in order) | 380 | ||
| Generator Pacing Parameters | 380 | ||
| Leads | 381 | ||
| Final Defibrillation Threshold | 381 | ||
| Final Zone Settings | 382 | ||
| Inside Back Cover | ES3 |