Case 2

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

CHIEF COMPLAINT: Abdominal pain HISTORY: This is a 70-year-old man who had a diagnostic sigmoidoscopy done 3 days ago for rectal bleeding. He is having some abdominal pain. He has noted some nausea and pain when he eats solid food. He says he feels better if he has only liquids, and once he has a bowel movement he feels better. When asked if he knew the results of his sigmoidoscopy, he replied that the doctor had told him he had some diverticula. He denies any diarrhea but said there is some constipation. He also denies chest pain or shortness of breath. He has had some coughing, but no other symptoms are noted. All other reviews of systems are noted as normal. PAST MEDICAL HISTORY: Positive for diverticulosis. No known allergies, no diabetes. Patient had thyroidectomy 25 years ago. EXAM: HEENT: Normal MOUTH: Partially edentulous; gums look healthy. HEART: Regular sinus rate and rhythm; heart sounds are good. LUNGS: Clear to auscultation and percussion. ABDOMEN: Soft; slight tenderness on palpation in lower left quadrant; no organomegaly; no masses palpable; bowel sounds good. GENITALIA: Normal male RECTAL: Good sphincter tone; guaiac testing shows occult blood; blood is noted upon visual exam. EXTREMITIES: No edema, ulceration, or discoloration; pedal pulses are normal. NEUROLOGICAL: Normal IMPRESSION: Diverticulitis with hemorrhage PLAN: We will begin antibiotic therapy with Flagyl.

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.

Flag question: Question 5Question 55 pts

What is the main term that leads to the ICD-10-CM code for this case?

Flag question: Question 6Question 65 pts

What is the ICD-10-CM diagnosis code for this case?