Case 1

Use the diagnostic statement in this case note to answer the questions using the ICD-10-CM Code Book.

Discharge Summary

ADMISSION DATE: 5/6/XX, Discharge date: 5/8/XX

HISTORY: The patient is gravida 2, para 1 and was seen in my office for all of her prenatal visits. Currently at 39 gestational weeks. 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.

Hints:

• Main term: The condition, check the Alphabetic Index for which term is bolded.
• Sub term: Check first vertical line indented under the main term for terms that describe the main term (condition).
• Remember to include all required characters and follow sequencing guidance provided in the notes.
• Review the notes and guidelines for Chapter 15.

Flag question: Question 1Question 12.5 pts

Which ICD-10-CM diagnosis code should be assigned for the outcome of delivery?

Flag question: Question 2Question 22.5 pts

Which ICD-10-CM diagnosis code should be assigned for the delivery?

Flag question: Question 3Question 32.5 pts

Which ICD-10-CM diagnosis code should be assigned for the weeks of gestation?

Flag question: Question 4Question 42.5 pts

Which ICD-10-CM diagnosis code for this case should be sequenced first?