Instructions: Review each case and identify the first-listed diagnosis.

1. Pain, left knee. History of injury to left knee 20 years ago. Patient underwent arthroscopic surgery and medial meniscectomy, right knee (10 years ago). Probable arthritis, left knee.


2. Patient admitted to the emergency department (ED) with complaints of severe chest pain. Possible myocardial infarction. EKG and cardiac enzymes revealed normal findings. Diagnosis upon discharge was gastroesophageal reflux disease.


3. Female patient seen in the office for follow-up of hypertension. The nurse noticed upper arm bruising on the patient and asked how she sustained the bruising. The physician renewed the patient’s hypertension prescription, hydrochlorothiazide.


4. Ten-year-old male seen in the office for sore throat. Nurse swabbed patient’s throat and sent swabs to the hospital lab for strep test. Physician documented “likely strep throat” on the patient’s record.


5. Patient was seen in the outpatient department to have a lump in his abdomen evaluated and removed. Surgeon removed the lump and pathology report revealed that the lump was a lipoma.


Part 2

Instructions: Match the diagnosis in the right-hand column with the procedure/service in the left-hand column that justifies medical necessity.

E 6. allergy test a. bronchial asthma

B 7. EKG b. chest pain

A 8. inhalation treatment c. family history, cervical cancer

C 9. Pap smear d. fractured wrist

G 10. removal of ear wax e. hay fever

I_ 11. sigmoidoscopy f. hematuria

J 12. strep test g. impacted cerumen

F 13. urinalysis h. jaundice

H 14. venipuncture i. rectal bleeding

D 15. X-ray, radius and ulna j. sore throat

Part 3

Instructions: Review the following SOAP notes or Operative reports to select the diagnoses that should be reported on the CMS-1500 claim. Then assign ICD-10-CM codes to diagnoses. (The level of service is indicated for each visit.)

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